Why is this guy's glucose 230? more...

CHATSDALE · Nov 7, 2005

is he on hyperal?

what was blood sugar before surgery??

lots of varables here including the trauma of the surgery

purplemania, BSN, RN · Nov 7, 2005

what shape was his pancreas in before and after the surgery? Maybe he was already diabetic. Maybe his pancreas was injured. Is he on steroids? How is he being fed? Formulas are notoriously high in glucose.

rogramjet · Nov 7, 2005

He may be a diabetic.

He may have a family hx, or other risk factors. Sometimes trauma will push those at risk people over the edge.

If he is a diabetic he may have an infection. Infections are a stress and will raise BG. He is on antibiotics, is this a preventative thing, or does he have an infection. Often times elevated BG is a warning sign of infection in diabetics.

Is he normally a physically active diabetic. Inactivity will raise BG.

Surgery is a stress, stress raises BG levels. Fight or Flight...elevated BP, HR, and BG.

His liver may be pumping sugar for him since he isn't eating, glyconeogenesis.

Lots of reasons. Don't stress about it. In the real world there are no black or whote answers...just lots of gray. What we would probably do is just give him insulin and try and figure out why later.

mitchsmom · Nov 7, 2005

That description was pretty much all the info on the case study. Didn't say if he was diabetic, or previous glucose's, or if on TPN. Oh yeah I do have more: alcoholic, malnourished, paralytic ileus (one of the questions was what form of nutrition would be appropriate (I got that!).

I don't know about steroids... that is the next question, whether steroids are useful in sepsis. I also know he's not in septic shock at this time because that's the next part of the case study.

It's a case study from a book, so I think they had something in mind for an answer. The actual question says:

"What explanation could account for Mr. M's serum glucose of 230 mg/dl?"

Hmmmmm

VickyRN, MSN, DNP, RN · Nov 8, 2005

That description was pretty much all the info on the case study. Didn't say if he was diabetic, or previous glucose's, or if on TPN. Oh yeah I do have more: alcoholic, malnourished, paralytic ileus (one of the questions was what form of nutrition would be appropriate (I got that!).
I don't know about steroids... that is the next question, whether steroids are useful in sepsis. I also know he's not in septic shock at this time because that's the next part of the case study.
It's a case study from a book, so I think they had something in mind for an answer. The actual question says:
"What explanation could account for Mr. M's serum glucose of 230 mg/dl?"
Hmmmmm

Hint: Think fight or flight... the patient is under tremendous stress. Glucocorticoids are being excreted from the adrenals in response to the stress... what do the glucocorticoids do to blood sugar?

neneRN, BSN, RN · Nov 8, 2005

A severe infection, i.e., sepsis, causes an acute stress response; stimulating catecholamine release. This in turn stimulates glucagon secretion, which causes hyperglycemia.

Also, look at his kidney function (creatinine). Many septic pts will go into acute renal failure, and this too can contribute. Glucagon is metabolized by the kidneys, and with loss of that function, glucagon and glucose levels rise.

mitchsmom · Nov 8, 2005

Thanks so much everyone!! :)

Daytonite, BSN, RN · Nov 9, 2005

The most obvious answer to your question is the great stress this patient is under. However, I notice that they are covering this guy with three antibiotics and his white count is still elevated after 3 days. I would like to know what they found in the peritoneal fluid. Some years ago I worked on a surgical unit where we had a lot of post-op trauma patients who had been shot. There is the possibility that the pancreas and/or the liver was injured, it was not discovered in surgery and there is now a potential pancreatitis. Bullets will ricochet inside the body and tear up the internal organs. Sometimes there is so much of a mess in the gut that a small nick or tear may not be noticed, particularly if they don't seem to be in the direction the bullet took. All the antibiotics in the world won't help in that kind of a situation. I have seen it happen a number of times where the patient had to go back to the OR for another exploration only for the docs to find some small nick that got missed the first time that is now causing all the current problems. I am also wondering what the circumstances were surrounding the shooting. If it was drug related, then there is a possiblity that you are dealing with a patient who is a drug abuser and hasn't or won't admit it. Liver and pancreas problems are very common in long term drug abusers and the stress of this event may have pushed this patient's body to the limit. Ascites is not a normal sequela of an abdominal gunshot wound that has been repaired unless there is peritonitis, but changing antibiotics should bring that under control. What I saw were patients like this who, once the missed injury was repaired, made rapid recoveries.

ZASHAGALKA, RN · Nov 9, 2005

1. More often than not, vented pt's are on steroids and steroids raise blood sugars.

2. stress reaction.

In a non-diabetic, it can be normal for a vented, steroided pt to have sugars over 200.

Incidentally, the new thinking is to put those pts on insulin gtts to get them back under 120-140. I went to a class at the AACN's annual conference that suggested that step alone could improve survival by upwards of 40%. (A non-diabetic's system isn't used to dealing w/ insulin delivery problems - that's a major stressor on an already stressed system that NEEDS that glucose.)

~faith,

Timothy.

ImaERtraumaRN · Nov 12, 2005

1. More often than not, vented pt's are on steroids and steroids raise blood sugars.
2. stress reaction.
In a non-diabetic, it can be normal for a vented, steroided pt to have sugars over 200.
Incidentally, the new thinking is to put those pts on insulin gtts to get them back under 120-140. I went to a class at the AACN's annual conference that suggested that step alone could improve survival by upwards of 40%. (A non-diabetic's system isn't used to dealing w/ insulin delivery problems - that's a major stressor on an already stressed system that NEEDS that glucose.)
~faith,
Timothy.

Yes, our hospital is doing an aggressive study on managing glucose levels in the ICU. We use something called a Glucommander. It is a laptop that is kept at the bedside. You put in MD parameters for CBG and parameters for insulin drip calc. The Glucommander requires (and alarms) every hour, the nurse checks the CBG, enters the results into the Glucommander and the Glucommander calculates the adjusted insulin drip rates. The nurse is responsible for actually changing the drip rate. It is wonderful for real-time glucose control. When the sugar is managed for an amt of time specified by the MD, the nurse requests MD orders for basal SubQ insulin and sliding scale management. We use it in the ED for hyperglycemic pts and can D/C the drips after the sugar is managed. In the ICU it is used ongoing for pts who need glucose control.