Where's the infection?

KatieMI, BSN, MSN, RN · Mar 24, 2015

If it were my will, I would expressively prohibit sliding scale short-term insulins. Either do it as it supposed to be done (CBG checked when patient's plate is there and he desided what he will and won't eat, glucose-elevating effect calculated and appropriate dose of ultra-short term insulin given while already eating, with periodic measurements right before meals and at night and correction of basal insulin dose done accordingly) or just put everyone on pumps, they are not so expensive nowadays. Just don't treat anyone's diabetes as if clinical pharmacology does't exist.

KatieMI, BSN, MSN, RN · Mar 24, 2015

Glucagon accentuates actions of adrenaline, and thus can cause WBC elevation through "stress pathway". But, again, there will be no young forms and no high content of neutrophiles in formula count.

jgcadet · Mar 24, 2015

Elevated WBC doesn't mean infection always, does she have a left shift? Lactate?

Sounds stress induced. What's her kidney function?

mmc51264, BSN, MSN, RN · Mar 25, 2015

just put everyone on pumps, they are not so expensive nowadays.

They are still >$10K AND you would have to have someone change the insets Q3 days. Not really an option for most DM2s.

Most nurses I know wouldn't know the first thing about a pump. Heaven forbid a CGMS. I have a child with a pump for 9 years; CGMS for 6 months. Godsend to us, but there is a learning curve.

JustMeRN · Mar 25, 2015

An elevated white count isn't necessarily an infection. How about differential?

Personal not work experience. My dad had a mildly elevated white count off and on for years. Pcp always said "you must have a virus". A couple of years ago he had a stroke. The hospital wouldn't discharge him because he had an unexplained elevated white count, I believe 18 or so. Couldn't pin point an infection anywhere. Went home, then rehospitalized at a different facility for additional stroke. They ran additional tests and the elevated white count turned out to be a chronic lymphocytic leukemia. Looking back he had had the elevated abc, elevated lymphocytes, no left shift. So, maybe it's not an infection but another process?

Glycerine82, LPN · Mar 25, 2015

Yep, I think there needs to be a diff as well as previous lab results, to see if she runs high normally. Big difference if she usually runs around 6k vs 11k, for example.

Anna Flaxis, BSN, RN · Mar 25, 2015

I work in the ER and had a diabetic pt today. Per the nursing home, pt hasn't been able to maintain her blood sugar. She's had continual bouts of hypoglycemia and has been given 3 vials of glucagon within a 24h period. They called the ambulance when she became unresponsive. Medics checked her blood sugar upon arrival and it was in the 90s but she was still unresponsive. Pt awoke en route to the hospital, rechecked sugar; it was 83. Upon arrival pt was aox3. Labs were done, urine was collected, pt had a CXR, and abdominal/pelvic CT. The CXR and CT were unremarkable. Pts WBC was 15.7, electrolytes normal and all other labs were WNLs, urine was negative.
What's the source of infection?

To recap: Other things can elevate WBCs, from tobacco smoking to intravenous glucagon (I did some poking around and found out that glucagon raises WBCs, including neutrophils and bands).

Inflammatory processes as well as anything that causes tissue necrosis, such as burns or MI can elevate WBC count (keep in mind that some diabetics with severe neuropathy can have "silent" MIs, and MI in which the patient does not feel typical MI symptoms such as chest discomfort).

Viral infections cause cause elevated WBCs.

Fungal and parasitic infections can cause elevated WBCs.

There can be hidden bacterial infections such as osteomyelitis. How is the patient's dentition? Folks with poor dentition can develop bacterial endocarditis.

As others have mentioned, a differential would be helpful.

motherof3sons · Mar 25, 2015

Another thought---we just had a resident have labs and her WBC was 20.7 and I first thought infection....then dug deep into her medical records and found she had CLL.