I hate hyperglycemia...

[brainfailure]

Hey Guys. I'm a lurker not a poster, usually, but I had a pt yesterday that I thought would be straight-forward, but it really had me kinda frustrated.

41y/o diabetic lady comes in Friday evening complaining that she had a headache, but now it's totally resolved. She knows its from her sugar being too high because two days ago she ran out of insulin. So, I check her labs and sure enough Glucose in 330s, but no DKA, no HONKC, nothing scary. She normally takes like 15u lantus daily and like 10 of 70/30 on top of that (honestly, i forget the exact dosages, but it was more than 20u/day). I give her a liter of saline and 4u of regular subQ (which I really consider to be not a huge dose). My goal was to hydrate her up a little and get her sugar under like 250ish then refill her insulin, tell her to go to her primary, and I'm done.

So, a little while later, the nurse tells me that this lady's accucheck is 50. So I get her to drink some OJ and give her some graham crackers and it comes up to 80s. Since we have a computerized record system, I look her up and I found an admission like 4 yrs ago for Hyperglycemia/DKA where she became hypoglycemic during her treatment. On the discharge summary, the resident wrote that she had very labile blood sugars and would often get hypoglycemic with just a little insulin. So, when I got comfortable that her blood sugar was OK, it was time to figure out a disposition. So, I was really uncomfortable writing for insulin for her to go home on. I was afraid to make her hypoglycemic. At the same time, she walked in with a blood sugar of 330 so I knew she needed some control. I ended up running it by my attending and he agreed he wouldn't write for insulin, and he said to discharge her with an appointment for our hospital's diabetes clinic on Monday (this happened Friday night). His point was hypoglycemia kills you and hyperglycemia over the weekend wouldn't really do anything.

That was ultimately what happened, but was it the right thing to do? Should I have written for insulin? Should I have admitted her for her sugars? Should I have gone House on everybody's ass and looked for some weird insulinoma or something? Was giving 4u of regular subQ wildly inappropriate?

---

Members don't see this ad.

 

[USCDiver]

FSBS 330, asymptomatic in a patient who ran out of their insulin probably doesn't need anything in the ED. I would probably have done what you did. Check her labs for acidosis and give her a liter of fluids. Recheck FSBS and d/c home with PCP followup.

If she seemed reliable with her glucose checks at home and had been on the same insulin regimen for a while, I may have given her a refill Rx.

Was she symptomatic with her FSBS in the 50s? That may not be low for her and she probably hadn't eaten anything in a while if she'd been in the ED all day.

 

[Aloha Kid]

She didn't get that way in a day, just for you. Her fantastic Glc control was a long time in the making and no single ER visit is going to change that. Agree with the attending Hypoglycemia kills not simple benign hyperglycemia.

 

[kungfufishing]

I dont chase hyperglycemia or asymptomatic hypertension.

 

[GeneralVeers]

If the glucose is over 330, I usually give a test dose of insulin to see the response. In general once I get them under 300 they go home.

If your patient goes into DKA and suffers hospitalization, the lawyers could always say that you knew she had hyperglycemia and were negligent by not intervening.

 

[DrQuinn]

I would save the patient an IV stick and just give her some SQ lispro and recheck in 2 hours, acuchek all the way. LIke someone said her sugars haven't gotten that way over a day, this is a chronic issue. If she can get an appt in three days ina diabetic clinic that's even better.

Q

 

[roja]

I dont chase hyperglycemia or asymptomatic hypertension.

ditto

 

[bartleby]

Often, you will find that people who are hyperglycemic will often drop a fair amount (50-100) after a liter or so of crystalloid. I find myself waiting to given them insulin based on where they wind up after a little bit of fluid if they're looking dry and they're not acidotic (so discharge is planned). If this lady went down to 250-280 just with hydration, it is perfectly reasonable to "do no harm" and refer her to the diabetes clinic. The internists (god bless them) can play with her meds over the long term and try to break the cycle of things which contribute to her poor control (big mac addiction, lack of physical activity, lack of adherence to a fixed meal/med schedule).