HYPOGLYCEMIA:Seizure...code

[EJSRN, BSN, RN]

Had a patient today who is a "frequent flyer" in our hospital. She is 27 years old and have MANY health problems. She is a very brittle type 1 diabetic and her glucose can go from 490 to 33 within an hour.She is on a continuous Dilaudid drip and last night was given an ambien for sleep.Most of the morning she was very drowsy, and non-verbal. She was NPO for a test (CT scan of abdomen i think), and right after she was given the barium she started to seize. They brought her back upstairs and as she was seizing she turned completely gray and her resps were labored. We checked her glucose and it was a critical low... meaning the lab had to come and confirm. At that point we were just about to give D50 when the charge nurse said "wait we want the Lab to draw first for an acurrate reading."

Why would you wait when the pt was NPO,and was having very obvious s/s of hypoglycemia? We did end up giving it first, and then the pt aroused a bit. Later that day she seized again, and this time her FSBS was WNL. We ended up calling a code, stabilizing her and then sending her to the unit.

I guess I just feel things werent done quickly enough. When she was unresponsive this morning something should of been done, and then after the seizure activity the doc should of ordered something... Any insights?

[leslie :-D]

i'm thinking a reaction to the barium/contrast media...

which i thought was contraindicated (or used very cautiously) for those with dm, specifically diabetic nephropathy or renal impairment.

that would be my guess.

leslie

[RN1982]

I wouldn't have waited for lab to come and confirm a critically low blood glucose. It's already low, I could care less what the number is.

[nurselsteele]

I have to agree, the labs well they speak for themselves but the life of that patient should come first. Our meeters read

I'm on your side, i would have ran the d5w & let them yell later!

[vamedic4, EMT-P]

I wouldn't have waited for lab to come and confirm a critically low blood glucose. It's already low, I could care less what the number is.

Agreed. Giving D50 for low blood sugars saves her life. Giving it for a higher blood sugar (say, if her BS were 320) isn't going to kill her.

And maybe they should review NPO policies for patients like yours. Was she NPO for a full 8, just 4 hours? Either way, if she's as brittle as you say then perhaps next time her blood sugars should be checked much more often. That way you can have a better idea of where her blood sugar is on a more consistent basis. It makes no sense for a patient that unstable (with regard to her blood sugars) who's diabetic, and NPO, not to have had frequent blood sugars done.

Low blood sugar can kill you, now you've seen it for yourself.

Glad she's okay! And I hope your next shift is better than your last one.

[suanna]

At my hospital if glucose is low :

[Southern Fried RN]

There is NO way I would have waited on the lab to confirm a critical low on a bedside meter. I would have probably used a second meter but going through the process of having lab draw the blood, then run it....forget it!

What if she had an anoxic brain injury from continual seizing that wasn't stopped because the lab hadn't confirmed the critical low? How would that sound on the witness stand if that woman's family sues? Your charge nurse could very easily throw you under the bus in court. ("I never said that") You knew what was right, don't second guess yourself.

If this patient is so brittle, on a Dilaudid drip, had altered mental status and then had a seizure, why in the HECK was she not admitted to ICU in the first place?

I heard of a pt in our CCU once who had hypoglycemia for almost 12 hours, she ended up with irreversible brain damage. She was on a vent and sedated so they happened to catch the low blood sugar on the AM chem 7.

[iluvivt, BSN, RN]

That nurse showed poor critical thinking skills. First.the technology is so good now I would trust the critical value and give the D50. All the nurse had to ask herself is "what harm could come to the patient if I give the glucose and she does not need it..........not much ....a high BS. What harm could come to the pt if she needs the glucose and I do not give it now......... potentially quite a bit,,,,,,,,,There is the answer ...GIVE IT.

[Tait, MSN, RN]

I agree with Southern Fried, that patient should have been in the ICU if she was that unstable to begin with.

Tait

[blondy2061h, MSN, RN]

No frickin' way would I have waited for the lab to come.

I'm lucky, with all of my patients having central lines, we draw our blood for glucoses off the line into a 3cc syringe. If they're on a drip, I squirt it onto the glucometer for a reading. If they're just on q6h SSI I send the blood to the lab in the first place (unless they're having obvious hypoglycemia, like your patient).

Then, when I run the result, if I get a critical level I go adjust their drip appropriately/give d50, and later, once they're stable, put the rest of the blood int he 3cc syringe in a lime top tube and send it to the lab. All takes about 5 minutes, so it's not like the blood is sitting out forever, and then I have blood drawn from before any treatment to send to the lab without delaying treatment.

It's obviously not practical without a central line, but if your patients that do have central lines, I've found this works wonderfully well.

[heron, ASN, RN]

OP, you were right about giving the D50 right away. I would have done the same thing.

Your question about something being done when the pt was unresponsive in the morning is a bit harder to answer.

First you said she was drowsy, then later you said she was unresponsive in the morning. A couple of questions come to mind.

How old is she and why is she in the hospital?

Why the dilaudid drip?

What's her baseline level of consciousness and mental status?

Was she on routine fingersticks and what was it that morning?

So which was it: drowsy or unresponsive?

What were the other assessment findings?

Any co-existing medical issues that could be in play here?

Depending on the answers to these, I could do anything from watch and wait to a full-tilt-boogie rapid response call.

I agree that after the first seizure episode, there should have been orders for at least some ativan to control active seizures while they figured out why she seized in the first place.

Very interesting situation ... thank you.

[Mulan]

Why didn't CT call a code or a RR if you have that, instead of transporting a seizing patient back to the floor?