Profound hypoglycemia after d/c sodium bicarb gtt

[WWRN]

Okay all, I have exhausted my internet research abilities and cannot find a reasonable answer to the patient situation I encountered recently. I need your help because I can't stand not knowing what was happening to my patient...

Pt had been severely acidotic and was placed on a D5W and Sodium Bicarb gtt at 250ml/hr -- was getting about an amp of bicarb per hour. Glucose levels were in the mid 200s and the acidosis had resolved so the gtt was d/c'd and 1/2 NS started at 75ml/hr. Pt's next glucose (about 3hrs later) was in the 120s. Before the next scheduled CS the pt's BP plummeted requiring the addition of a Levophed gtt. By the time the next CS was due the pt was on 14mcg/min of Levophed and the CS result was 35!!! Pt was given and amp of D50 and the BP immediately improved to the point that I was able to decrease the Levophed to 4mcg/min. Repeat CS 116. Next CS about 45 min later was 82. An hour after that the CS was 63...

This pt was in acute renal failure -- about 4L positive with 60cc urine output in 24hrs. My charge nurse said something about the Bicarb being withdrawn so rapidly and the failing kidneys led to the glucose issues, but couldn't really explain why...

I'm really curious to know the possible link between the bicarb gtt, hypoglycemia, and hypotension that vastly improved when the glucose was corrected.

Any light you can shed on this would be greatly appreciated. Thanks in advance!

[mediatix8]

250cc/hr is pretty fast. So Dw5 with bicarb was d/c'd and then the blood sugars started dropping. I don't know about the bicarb, but if a patient has been getting dw5 continuously @ 250cc/hr, the body gets used to that much glucose and produces insulin thinking it's going to continue to get d5w @ 250. Then you suddenly stop it but the body is still producing more insulin, thinking that it's getting the d5w @ 250 still. Same concept for why babies of a diabetic mother could end up hypoglycemic after birth.

[rkitty198, BSN, RN]

Sounds like the patient may be suffering from a multi-system failure?? Acidosis and renal failure are probably the culprit rather than the bicarb drip.

Systemic failure (I think of this because of the patients inability to maintain blood pressures)

What I think...(I am going to try here) :)

When the kidneys fail insulin is unable to degrade via the kidneys which can prolong the half-life of the endogenous insulin.

The body is in such a state of shock that it is unable to release catecholamines in response to the hypoglycemia in order to potentiate gluconeogenesis.

= hypoglycemia

[GilaRRT]

250cc/hr is pretty fast. So Dw5 with bicarb was d/c'd and then the blood sugars started dropping. I don't know about the bicarb, but if a patient has been getting dw5 continuously @ 250cc/hr, the body gets used to that much glucose and produces insulin thinking it's going to continue to get d5w @ 250. Then you suddenly stop it but the body is still producing more insulin, thinking that it's getting the d5w @ 250 still. Same concept for why babies of a diabetic mother could end up hypoglycemic after birth.

Pretty much agree. Five percent dextrose gives you 5 grams per 100 ml. This patient was receiving 12.5 grams per hour. Just to clarify the intuition, we took a patient who was receiving half an amp of D50%W per hour and suddenly discontinued their dextrose infusion.

[Esme12, ASN, BSN, RN]

I agree with everyone. Another similar cause with the acid base balance all thrown off from renal failure is a Hyeprosmolar Non-ketotic syndrome and with the abrupt withdrawl of the glucose you had a rebound drop of glucose due to poor glycogen stores in the presence of renal failure,

and being placed in a hyperosmolar state with the bicarb.....a link

http://www.medschool.ucsf.edu/sfghres/password/IS/1IS_DKA.htm

[leslie :-D]

how was the pt's k+ level?

(thinking that hypokalemia will cause hypoglycemia)

leslie

[CCL RN, RN]

Plain and simple: you stopped his glucose gtt! 1/2 amp/hr is a lot, and sounds like he needed it.