Patient's Sudden Severe Hyperglycemia

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Specializes in IM;Nephrology; Intellectual Disabilities.

I want to know your thoughts on this scenario:

A pt who is normally cognitively impaired starts having fatigue. She is taken to a walk-in clinic, where they swab her for strep (by the way:no fever, elevated pulse, or elevated blood pressure). Strep is negative. They send her home on antibiotics. She is taken to the ER a couple of days later when she is unable to stand without assistance -- at that point, it is obvious that there is something really wrong. There had been no symptoms besides the fatigue previously. (By the way, the pt is non-verbal.) At the ER, they do a CMP, and her blood glucose level is 1400. (SERIOUSLY.) She had no prior history of diabetes, and her blood sugar was last checked 6 months before this incident. It was well WNL at that time. She has a history of HTN, but it is well-controlled with medications. So... My first thoughts are: Does she have pancreatic cancer? After they began to get her blood sugar under control (this physician's idea of well-controlled BS is in the 300s, apparently), her potassium started dropping (I assume from all of the insulin). I'm a little frustrated with the fact that they are not trying to find the cause of the elevated blood sugar but just assume that she is now a diabetic. Have you known for a pt to have a blood sugar that high out of nowhere and it just be her having diabetes? I know I'm not wording this correctly, but I currently battling with a bit of frustration. I'm not working in the hospital where she is located (I have recent experience in acute hospital care, though), but I manage her medical care at her group home. I just wanted to know what other nurse's thoughts were on this issue.

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My first thought was cancer as well. It would not be inappropriate to suggest a cancer workup to her care team. Good luck!

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Specializes in Neuro ICU and Med Surg.

How old is this patient? Is she young

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Specializes in Oncology.

I'm curious how old this person is as well. Type 1 diabetes is sudden onset, and can be seen in anyone. Typically to get a glucose over 1000 it take renal impairment as well. What were her kidney functions like? I'm surprised labs weren't done at urgent care. How long has it been that she has been on insulin? Glucose a in the 300s are expected initially. They can't lower glucose too quickly.

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Specializes in CMSRN.

Was the patient in DKA? Or HHNS without spilling ketones or having any acidosis? HHNS can come on without warning and is generally seen with pt's >600 glucose and in patients never previously diagnosed with diabetes. It usually follows illness and that's why I thought of it and is more closely related to a new diagnosis of type II diabetes.

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Is the patient on any mood stablizers? Lithium is what can cause someone to have kidney issues. Additionally, what antibiotic was the patient on? Sometimes (and levaquin is huge for this) it can cause acute renal failure. Therefore, a "borderline" blood sugar can be spiked high with renal failure. And a WNL blood sugar can be subjective and facility based. Some want it below 100, others below 120---was the patient fasting--all sorts of variables. Diabetes can come on fast and furious. And without FBS monitoring for any length of time hard to know if after the patient eats it goes to 200 or more without monitoring. But the patient being non verbal, hard to know. It would be good to know what the patient's kidney function (BUN and creatine) and creatine clearance is.

It will take FBS for a length of time and perhaps a sliding scale. However, I would not rule out kidney issues as well.

Good luck and let us know what happens.

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Specializes in IM;Nephrology; Intellectual Disabilities.
My first thought was cancer as well. It would not be inappropriate to suggest a cancer workup to her care team. Good luck!

I finally addressed that question with the NP who was involved in her care, and she told me that all of her enzymes were good, and her CT scan did not show any abnormalities.

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Specializes in IM;Nephrology; Intellectual Disabilities.
How old is this patient? Is she young

The patient is in her early 60s. She never spilled any ketones, but her electrolytes were all out of wack. I know that some patients can become hypokalemic on insulin, and I assumed that was why her potassium was low. With all other electrolytes, I'm not familiar with the relation.

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Specializes in IM;Nephrology; Intellectual Disabilities.
I'm curious how old this person is as well. Type 1 diabetes is sudden onset, and can be seen in anyone. Typically to get a glucose over 1000 it take renal impairment as well. What were her kidney functions like? I'm surprised labs weren't done at urgent care. How long has it been that she has been on insulin? Glucose a in the 300s are expected initially. They can't lower glucose too quickly.
Her creatinine and BUN were slightly elevated, but they became normal after fluids were replaced. I was shocked that she didn't have any renal impairment -- if not before, then secondary to this event. I have 30+ clients whose medical care I manage. I generally am not able to go to all appointments; but I'll make time for the ones that I intend to question physician's orders, etc. In this case, I didn't think it was necessary to go, because her only symptom was fatigue and her vital signs and head-to-toe were all WNL. (I assessed her myself the day before we decided to send her to urgent care.) Since then, I have decided that if the urgent care is necessary -- on the weekends and when primary physicians are out of the office -- I will either be accompanying the patient or, at least, sending a list of tests that need to be run (ie: labs, x-rays, etc.). I decided to take another patient -- also experiencing fatigue and unable to verbalize her needs -- to the urgent care center only days after this incident. This time I accompanied the house manager and the patient. Prior to deciding to take her, I was watching her eat lunch, and she coughed just slightly while she was drinking her milk. (Light bulb goes off in head. "Aha! Aspiration pneumonia!") Her primary physician's office was closed for the week, so we had to take her somewhere. I do not like sending my patients to the ER unless it is absolutely necessary. The NP at the urgent care center listened to her lungs and stated that they sounded clear. I pushed her to order a CXR any way -- "Just in case..." -- and she accommodated. The CXR showed RLL infiltrate! So, from now on, I go with my gut... In the first scenario, though, I had no idea what was going on. As we were taking her to the ER, I suspected UTI (and was correct), but I had no idea that her blood sugar was so high.
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