Jump to content

What would you do for hyperglycemia?


Recommended Posts

Question... would we be running fluids wide open and pushing 1000cc of NS or LR into a patient with potentially undiagnosed and certainly uncontrolled diabetes? Wouldn't there be a concern about kidney function, as in if they aren't functioning fluid overloading the heart and leading to lots more issues?

In theory yes. A patient with renal impairment or renal failure may not pass as-large a volume of urine typically seen with DKA/HHNK so may not be as dehydrated.

They should still receive intravenous fluid as there will be some degree of dehydration due to osmotic diuresis which requires correction.

I'm all for giving fluids and they way it was explained to me was you want to almost dilute the sugar in the blood... but I am hesitant to push through a lot of fluids on the way to the hospital, unless it's over a long period and you can closely monitor ECG and lung sounds....

You want to begin to replace the water deficit so fluid is a good idea (these patients often require 3-5 litres of fluid).

"A lot" of fluid is a subjective term; hang up a one litre bag of NaCl at TKO and start the process.

Of course it goes without saying clinical judgement is required (damn that clinical judgement, makes them textbooks much thicker!) so if your patient suddenly develops massive SOB and crackles then perhaps turning the fluid off is a good idea.

Link to comment
Share on other sites

I've seen quite a few diabetics with BGLs over 500, yet none of them have been in big trouble when there were no comorbidities, at least not that I could determine or learned of later.

Chbare are you saying that there are times when pts crump, (not talking zebras), from straight forward uncontrolled diabetic issues at this level? What would be the likely mechanism in such a patient?

Not a challenge but a genuine question. The only time that I've really seen even altered hyperglycemia they've been around 1000 or so. But my experience with such things is certainly not deep. One other time I had an altered diabetic at 1550 per ER blood work, and he was dead about 5 hrs later, though there was no reliable information as to how long he may have been in such a state before discovered and EMS activated.

Pretty cool thread...

Dwayne

Going strictly off of lab assessments DKA is characterised by a sugar over 300 mg/dl, presence of ketones in the urine and elevated ketones in the blood, a Ph less than 7.3 and a low bicarbonate. The acidosis is most often going to be an elevated anion gap acidosis.

Anecdotally, I've seen very sick patients in the 500's and rather unremarkable patients in the 500's. Again, anecdotally, the sickest DKA patients that I have seen were newly diagnosed children with sugars in the 600's/ Once, I have a critically ill patient who had sugars in the 400's, but she was a well known, non-compliant type I patient with other co-morbid factors. An elevated blood sugar is not particularly sensitive or specific on it's own. In fact, an elevated sugar is not it's own problem per se, it's an indication of more complex pathology occurring. Perhaps it is related to illness, stress, DKA, or even steroids. It is rather difficult to differentiate in this situation because the OP still has not provided us with additional information.

Question... would we be running fluids wide open and pushing 1000cc of NS or LR into a patient with potentially undiagnosed and certainly uncontrolled diabetes? Wouldn't there be a concern about kidney function, as in if they aren't functioning fluid overloading the heart and leading to lots more issues?

I'm all for giving fluids and they way it was explained to me was you want to almost dilute the sugar in the blood... but I am hesitant to push through a lot of fluids on the way to the hospital, unless it's over a long period and you can closely monitor ECG and lung sounds....

Am I way off base?

If we are treating something like DKA, it would not be uncommon to administer one, two or even three litres of isotonic fluid in the first hour. As sugars and the anion gap close, you often see a change to D5-10% in 1/2 NS or transition to some other related solution. Often, we will add Potassium as well because the total body stores of potassium are actually low even though the serum potassium will often be elevated. The fear of renal issues is real; however, fluids will be helpful. Yes, you may have a patient with co-existing CHF; however, these patients are still going to be dehydrated and will need fluid replacement. Also, many CHF patients are in fact fluid depleted in many cases, but that is for a different discussion.

Link to comment
Share on other sites

Makes sense... It's been a while since being in the field and now that I've thought it through more makes sense. Where I came from, transports were usually <10min on a bad day so I guess to me the thought of running fluids WIDE open on anyone was rarely done unless hypovolemic and/or hypotensive... I'd rather let the hospital in a more controlled setting with more education around handle the fluids on this patient. Doesn't mean they wouldn't be started but like kiwi said...start TKO then open up slowly...?

Link to comment
Share on other sites

1000 cc of NACL wont hurt anyone (assuming this is an adult patient)

Acute renal failure, end-stage renal failure, congestive heart failure, psychogenic polydypsia, severe hyponatremia and those are just the few off the top of my head.

I have to agree with crotchity on this one, treat the patient, not the machine.

Most misguided statement ever. I cannot believe this still gets said.

As for the rest of the discussion, I don't think it is necessary for EMS to give insulin. Fluids and rapid transport should be fine. Even in the sickest pts they are not going to get better right away.

  • Like 2
Link to comment
Share on other sites

Duuuuuuuuuuuuhhhhhhhhhh, I think I said give fluids, sorry you always believe the machine over what you see with your eyes. There are lots of diabetics (non-conforming with treatment) that walk around with a glucose of 400-500 every day.

Link to comment
Share on other sites

Acute renal failure, end-stage renal failure, congestive heart failure, psychogenic polydypsia, severe hyponatremia and those are just the few off the top of my head.

Your head ... what are you, a Consultant Physician? :D

Psychogenic polydipsia eh? You've been into the E again haven't you :P

Link to comment
Share on other sites

Lol Doc, psychogenic polydipsia? Had to look that one up. ;)

Another example: stable hypotensive (MAP around 50) pt. with suspected internal bleeding.

Link to comment
Share on other sites

Duuuuuuuuuuuuhhhhhhhhhh, I think I said give fluids, sorry you always believe the machine over what you see with your eyes. There are lots of diabetics (non-conforming with treatment) that walk around with a glucose of 400-500 every day.

Your eyes can get us a creatinine, K+, Mag and Phosphorous? Do they get us a serum osmolarity?

Link to comment
Share on other sites

Duuuuuuuuuuuuhhhhhhhhhh, I think I said give fluids, sorry you always believe the machine over what you see with your eyes. There are lots of diabetics (non-conforming with treatment) that walk around with a glucose of 400-500 every day.

You truly are ignorant and/or lacking any medical knowledge. Why bother getting the test if you are not going to do anything about it? Yes, there are plenty of people walking around with uncontrolled sugars. They are the ones with retinopathy, neuropathy, renal disease/on dialysis, and cardiovascular disease.

Your eyes can get us a creatinine, K+, Mag and Phosphorous? Do they get us a serum osmolarity?

Eh, what difference does a K make? You are not going to treat their hypokalemia even if they have peaked T waves, because we treat the pt, not the machines.

Link to comment
Share on other sites

Eh, what difference does a K make? You are not going to treat their hypokalemia even if they have peaked T waves, because we treat the pt, not the machines.

In that case, I suggest that we do almost nothing and go to the hospital aggressively address the hyperglycemia pinkness and Kussmaul's respirations with large IV doses of NPH Insulin to rapidly return the bG to 60-100 mg/dl 4-10 mmol/L 5 horses / washing machine less pink and Kussmaully.

Regarding the hypotension weak radial pulses (them spymanomanomometers are machines too), I think we should give about 1-2 L of saline while considering baseline renal function and the potential need for bicarbonate, and being careful not to overresuscitate a bucket of NaCl -- it's salty like blood -- go hard or go home. We should consider the potential for hypokalemia and rebound ketosis with overaggressive insulin administration starting quadrilateral 10 gauge IVs, and the risk of hyperchloremic acidosis or hypervolemia with overaggressive fluid administration wearing a ball cap.

I'm now going to go to the hospital and tape over every piece of medical equipment I can find, so that they don't end up treating the machine instead of the patient.

Edited by systemet
  • Like 2
Link to comment
Share on other sites

×
×
  • Create New...