The sugar that just kept dropping...

Published

Have any of you ever seen a patient with hypoglycemia that just dropping despite every intervention?

I have never seen anything like what I saw last noc. Pt known diabetic, reports a 2-3 day "stomach bug" with nausea, vomiting, and diarrhea. Normally takes regular insulin, set dose, Q AM, along with PO hypoglycemics. States yesterday AM, FS was in the 40's, skipped AM insulin and PO meds. States po food intake decreased, but adequate. Certainly able to take PO- watched him eat a sandwich and down quite a lot of OJ. Family called EMS later that day for FS in the 30's.

Given before arrival to floor,

2 tubes glucose gel

4 Glucose tabs

2 mg glucagon

2 amps D50 IV

IV D5 1/2 NS @ 100ml/hr

Boxed lunch

Upon arrival to floor (sometime late in evening) ... FS in the 90's. Stayed up there only about a couple of hours, then in the 30's again.

Given between 11-7

4 amps D50

2mg Glucagon SQ (in seperate doses)

16 OZ per hypoglycemia protocol

IV D10 @100ml/hr

Seemed as though he'd barely hit normal after D50 AND glucagon, but only stay there for about an hour or so!! Current thinking... either OD on oral hypoglycemics or insuloma??? Many labs still pending when I left.

What a night, though!! FSBS was checked between Q15m after interventions!! and Q1h when >70. Total FSBS's for shift >15. Have never spent so much time on blood sugar in my life! Despite all of this... FSBS@6AM-55!!! Pt was being transferred to PCU level of care from tele when I left.

I'm exhausted. I think MY blood sugar is low from running around so much!

Up Vote Up Vote ×

God no, never had a situation that scary.

Up Vote Up Vote ×
Specializes in ER, ICU, Infusion, peds, informatics.

i've seen it before, but usually in someone in either liver failure or pretty severe sepsis.

and certainly not on telemetry.

i would think he needed icu -- not pcu. with q15min blood sugars, you can barely chart (on him!) let alone get anything else done.

Up Vote Up Vote ×

i would think he needed icu -- not pcu. with q15min blood sugars, you can barely chart (on him!) let alone get anything else done.

i made this point... more than once! the doc kept saying "but i ordered them q1hx2 until stable (which he never was)... to which i'd respond "yeah, but the hypoglycemia protocol makes me check 15 after each intervention... and good thing i did, 'cause 15 minutes after that 4oz oj per protocol, he went from 55 to 42!" i don't think i really got it through his head how much work this was... and with 3 other patients, one being an admit in the middle of all of this!

i would not be at all surprised to see the man in the icu when i go back in tonight. i agree, that's where he belongs!

it was the busiest night i've had in a very long time. just venting.

Up Vote Up Vote ×
Specializes in Med/Surg, Home Health.

Yep, had a patient just like that about 3 weeks ago. We gave amps of D50, she drank OJ, you name it. We just could NOT keep her sugar up. It stayed in the 30-40 range. We had to check her every 15 minutes and had to until her fsbs remained above 90 for 3 consecutive fsbs's. Then it went to q30 minutes, then q hour, then on regular schedule. I was sooooo glad to go home. I ran myself to death trying to keep her sugar up. I had initially suspected she had taken too much insulin at home, but she wasnt on insulin.

Up Vote Up Vote ×
Specializes in Trauma,ER,CCU/OHU/Nsg Ed/Nsg Research.

Try giving some kind of fat & protein (peanut butter works well) with the OJ next time in this type of situation to prevent a rebound drop in the glucose. OJ works to get the glucose up quickly, but will not sustain it, and may rebound back down.

Also wanted to ask- are you sure the pt wasn't taking Lantus in the evening at home?

Up Vote Up Vote ×
Specializes in ICU, PACU, Cath Lab.

We had this the other night too. Was not my patient but we were all working on trying to keep that darn BS up. Man that was all her poor nurse charted on all night. Thank goodness we are in the ICU and her other patient was stable. I do not know how you guys did it with 5 patients!!

Up Vote Up Vote ×
Try giving some kind of fat & protein (peanut butter works well) with the OJ next time in this type of situation to prevent a rebound drop in the glucose. OJ works to get the glucose up quickly, but will not sustain it, and may rebound back down.

Also wanted to ask- are you sure the pt wasn't taking Lantus in the evening at home?

Good point re: fat and protein. He HAD been eating PB and crackers prior to my arrival, but I was too busy thinking about getting that sugar up, and this didn't occur to me!

Yes, I'm sure, pt was not taking any lantus... just regular insulin and PO hypoglycemics.

Up Vote Up Vote ×

Hrmm interesting then. Be sure to let us know how they are doing tonight if they are still your pt. I'd be interested as to what would cause this (and wth with not sending them to the unit?).

Up Vote Up Vote ×
Specializes in PCU, Home Health.

Our policy also had us do q 15 min checks- always the fast acting carbs until it comes up, then the protein/fat.

I feel for you as it was completely inappropriate for the doc to deny your request to send the patient to icu. I think I would have had my manager and house supervisor in on this one.

Up Vote Up Vote ×
Specializes in ER, Infusion therapy, Oncology.

I have seen this several times, especially with patients taking glucophage.

Up Vote Up Vote ×
Specializes in Trauma,ER,CCU/OHU/Nsg Ed/Nsg Research.
Our policy also had us do q 15 min checks- always the fast acting carbs until it comes up, then the protein/fat.

I feel for you as it was completely inappropriate for the doc to deny your request to send the patient to icu. I think I would have had my manager and house supervisor in on this one.

ITA with all of the above.

Up Vote Up Vote ×
+ Join the Discussion