Hypoglycemia

[LibraNurse27, BSN, RN]

Hi all, just curious about hypoglycemia protocols at your organizations. Ours for diabetics is anything less than 70 gets treated and re-checked. For non diabetic pts it says report 54 or below and 500 and above. Reason I ask if we had a non diabetic pt w/ BG 63 in the AM labs that wasn't treated or re-checked. She was on D5LR. Clear liquid diet but not eating much. A lot of other abnormal labs, but she had stage 4 terminal gastric cancer, so MD said the high lactic and acidosis were related to tumor burden and tumor necrosis, not sepsis or dehydration. 

The pt and family had been advised to fill out DNR paperwork and transition to palliative, but wanted aggressive treatment. Pt went to IR for PEG placement, no sedation given, and she coded. No BG checked in the code, but later in ICU it was 34. I am wondering if the mild hypoglycemia in the morning could have worsened even though she was on D5LR and drank juice in the morning, and if this could have caused the code. I know there are many other factors and she was not a good candidate for a procedure, but looking for feedback. 

[EDNURSE20, BSN]

If a pt has low BGLs, especially if they aren’t eating too, I would be monitoring the BGLs closely. Protocol or not.

They are low enough to raise concern to the Dr IMO. If they don’t want to treat it, that’s on them. But if they were still allowed oral fluids I would of given them something to drink high in sugar first before approaching a Dr. 

[LibraNurse27, BSN, RN]

On 8/27/2020 at 9:25 PM, EDNURSE20 said:

If a pt has low BGLs, especially if they aren’t eating too, I would be monitoring the BGLs closely. Protocol or not.

They are low enough to raise concern to the Dr IMO. If they don’t want to treat it, that’s on them. But if they were still allowed oral fluids I would of given them something to drink high in sugar first before approaching a Dr. 

Thanks for your reply! I did give her orange juice and I planned to re-check sugar but have to admit I got distracted by a busy day and then suddenly she was being wheeled to IR. Not a good excuse, I know, and I should have handed off the labs to the IR team. I'm just really hoping her blood sugar had nothing to do with the code, but I can never know if it was low when she went since I didn't check and they didn't check during.

MD said she likely couldn't tolerate lying flat because her abdomen was huge and distended, and full of tumors =( Maybe it compressed the blood flow to her heart? I have been losing so much sleep thinking I missed something and caused her to die. sometimes being a nurse is so stressful. Everyone keeps saying it had nothing to do with the sugar, and that she was already so sick, but I still feel bad.

[kp2016]

2 hours ago, LibraNurse27 said:

MD said she likely couldn't tolerate lying flat because her abdomen was huge and distended, and full of tumors =( Maybe it compressed the blood flow to her heart? I have been losing so much sleep thinking I missed something and caused her to die. sometimes being a nurse is so stressful. Everyone keeps saying it had nothing to do with the sugar, and that she was already so sick, but I still feel bad.

I'm really sorry that things didn't go better for your patient and that you are now left second guessing / blaming yourself. I honestly don't think you did anything wrong and you certainly didn't cause the death of this patient. 

The sad reality is this patient had a terminal diagnosis and no amount of aggressive treatment was going to improve her prognosis. When doing C-Sections we do not lie patients in the regular supine position as the weight of the baby/ placenta compresses the inferior vena cava reducing blood flow to the mother and baby so I think your doctor is probably correct that the weight of the tumors caused a significant compression.

Honestly the blood sugars could have been checked in the code as it is part of the H's & Ts, but those are general guides only and it's very possible that hypoglycemia didn't cause the code so correcting it would not have helped or changed the out come.

It's also worth noting that checking blood sugars requires an order at most facilities so it very possible it would have been considered a "mistake" for you to have checked them when the patient didn't met the defined parameters. It situations like this all you can realistically do is document that you were aware of the lab, notified the team, that they didn't wish to give orders for treatment and that you continued appropriate monitoring of the patient.

To be clear I'm not saying that in general telling the team is the end of your responsibility to your patient, sometimes you do need to make multiple calls and involve supervisors but in this case I think it may have just been that nature took it's course.

Please don't beat yourself up over this. 

 

[LibraNurse27, BSN, RN]

Thank you so much @kp2016 I really appreciate your reply and reassurance. Also cool to know that about c-section patients, never would have thought about that! Thanks