help me figure out what happened :/

I have been thinking about this constantly.. Ok so a while back my patient coded and didn't make it that i was helping take care of all day. (im a nursing student) In fear of violating any hippa regulations im going to try to make this very general but basically my patient was on the unit after having an amputation related to complications of PVD. he/she had a history of cardiac complications. with this he/she also appeared to be in acute renal failure as BUN and Creatinine were both pretty elevated. He/She refused to eat the whole shift since she said she got sick the night before. towards the end of my shift he/she got a routine glucose check and it was very low (lower then 50 was not a diabetic) so his/her nurse got an order for Dextrose IV push. Shortly after given the IV push he/she began to become more alert but then suddenly became unconscious and coded. Her vitals were WNL all day and she appeared to be in stable condition. I just dont see what could have happened for him/her to slip away so fast at first i thought maybe it was the dextrose and his/her blood sugar skyrocketed but now im thinking otherwise. does anyone have any ideas on what could of happened? at the time he/she became unconscious vitals were taken and her o2 sat was down to 80 and blood pressure had skyrocketed (does not make sense to me). Even my clinical instructor couldn't really figure it out. It just has been bothering me that i cant figure out exactly what happened i feel like i missed something that should have seen...

Also throughout the whole shift the patient had 0 output, (was bladder scanned at 135ml) but had an intake of around 500ml. BUN and Cretinine levels were twice the normal limit from the day before, and updated lab results were not obtained because phlebotomy tried too many times unsuccessfully (there was a limit). Last edit by Studentnurse32 on Oct 29, '12
Without knowing all the details of vitals and so on it is hard to make a guess. I think the most likely cause would be a blood clot causing rapid PE, stroke, or MI. What was the BP exactly? What was the heart rate at the time? What was the anticoagulant status? Were they on insulin? Certainly the D50 did not cause this. I would also want to see the labs. If your instructor was stumped don't feel bad, sometimes the clinical picture is a puzzle.

The only thing that I can think of is looking at how aggressive the renal failure was coupled with the hypertension. I think the timing of the dextrose administration was probably more coincidence than anything else. This may be one of those cases where the only way to really know is an autopsy.I wouldn't stress about it too much. But it is very intriguing.

You say the vitals were 'normal' were they his/her normal? You might see a VS trend if you look back. I second what the others say. Sounds like an acute HTN episode or PE. Will you find out? If you do, let us know.

To me, it does not sound like the dextrose was the cause of the problem. I think it was probably coincidental more than anything else. The fact that the patient became more alert before slipping into unconsciousness tells me that the dextrose was beginning to do its job. With the SpO2 dropping and the blood pressure increasing, I can only think that what you were seeing was a compensatory mechanism for the increasing SpO2. It will probably truly take an autopsy to figure out what happened. Even then it's possible that the answer may never be known.

It wasn't the dextrose. That is just bad timing...dextrose doesn't do that. It says to push over 5 minutes, but when i have a patient who is unresponsive d/t low blood sugars i don't have 5 minutes. Pharmacy tells us "Just push it!" Anything could have happened really, without knowing symptoms that led up to it its hard to say. Like did they complain of shortness of breath? chest pain? dizziness? etc. Patient's can code from alot of different scenerios....my guess is with a random drop in BS with other subtle things there was something else brewing. I know you say BP are high, and i'll have students coming up to me scared out of their mind because their patient's blood pressure jumped from 130-150 systolic. it ok...Majority of doc's don't do anything unless its over 180. Certainly a BP at 130 or 140 won't cause a person to code. She could have thrown a clot, had an MI (Remember women have very subtle signs of MI that differ from men). Kidney disease wouldn't cause a code like that, unless they have lke stage 4 and are not being treated. PE is a possibility but there would be other signs that go along with this. Low urine output wouldn't concern me too much at this point because she was scanned at 135 you say? With renal disease this isn't unheard of. Could she have been fluid overloaded? Sure...but wouldn't cause a code lik this. With a significant cardiac history she very well could have just gone into a bad rhythm. Like if she had prolonged QT interval or anything else that could cause a bad rhythm. Who knows?? But it doesn't sound as if it was the fault of anyone. Stuff like this happens and often go unanswered as to why it happened.

Though what everyone else has said could quite possibly seem feasible. I am more inclined to think (though without labs, trending vitals, and pt history, it's a guess) someone who is in renal failure quite often has electrolyte imbalances. What was the potassium? Mag? Calcium. I have seen more codes from electrolyte imbalances than I would care to. I do agree that the D50 IVP was just coincidence. Don't get too hung up on it- good luck

Electrolyte imbalance is a good thought though. Like Laurel said...there are codes that are related to electrolyte imbalances. I work with post operative open heart patients, and i can tell you the one we keep an eye on the most (although all are important) is potassium. We have orders up the wazzzooo on wha to do when a potassium is every result you can think of. We also have PRN orders on medications to give if it is a certain level. Very similar to insulin and dextrose orders if you can imagine that.Reason im getting at potassium is there is a correlation of insulin and potassium. I don't remember exactly what is is, but you say her blood sugar was 50 (NO history of diabetes) so she could have, for some reason, had an increase in insulin uptake or production. This can cause hypokalemia. (pretty sure it is hypo over hyper). Either way, Hypo and hyperkalemia can cause rhythm abnormalities. Not a good combination for someone who already has known cardiac history. I'd be curious to know her potassium, mag levels etc. Good point Laurel

Threw a clot, sepsis, electrolytes off, Potassium, as noted on above post, acute renal failure-----or it was just a number of comorbitities that all came together for the perfect storm after surgery.I am sorry you lost your patient. That is tough no matter what. ((hugs))

By the way, as an aside, when you are practicing in your own nursing career--elevated BUN and Creat, no urine output, and a FBS of 50--Rapid Response, this patient should be sent to a higher level of care. Just an opinion, but don't ever be afraid to ask for assistance of others if your patient has a lot of major issues that become critical quick.

I don't think a higher level of care would be necessary on a med/surg unit for this type of patient. just because they have an elevated BUN doesn't mean they are a critical care patient. No urine output? yea thats not good, but not surprising since BUN/Cr is elevated. Doesn't warrant for higher level of care unless they were to become unstable. Also because thye had low blood sugar doesn't mean they need to be moved to higher level of care. I work on med/surg and we deal with low blood sugars, give them something to eat, maybe a little dextrose IV or some juice, check a few more blood sugars per protocol and call it good.

Quote from Jenni811I don't think a higher level of care would be necessary on a med/surg unit for this type of patient. just because they have an elevated BUN doesn't mean they are a critical care patient. No urine output? yea thats not good, but not surprising since BUN/Cr is elevated. Doesn't warrant for higher level of care unless they were to become unstable. Also because thye had low blood sugar doesn't mean they need to be moved to higher level of care. I work on med/surg and we deal with low blood sugars, give them something to eat, maybe a little dextrose IV or some juice, check a few more blood sugars per protocol and call it good.