A tragic transition of care
The story:
JR is a 32-year-old woman with a medical history of juvenile diabetes mellitus and end-stage renal disease on intermittent hemodialysis for the past 2 years. She was admitted to the hospital with shortness of breath and was found to have a large right-sided pleural effusion with loculations. Antibiotics were initiated. On hospital day 2 she underwent a video-assisted thoracoscopy for drainage, lysis of adhesions, and placement of two chest tubes. After returning to the floor from the postanesthesia care unit, JR had difficulty achieving adequate pain control despite a hydromorphone patient-controlled analgesic pump. Additional "as needed" intravenous morphine was ordered for relief. Before going home, the attending internist checked in on JR and discontinued her intravenous fluids (D5 half-normal saline), but wrote to resume her long-acting insulin later that same evening.
At approximately 7:30 p.m., JR was found by the nurse barely breathing. Her pupils were pinpoint and her respiratory rate was only 5 breaths per minute. A code blue was called and a hospitalist responded. A combination of epinephrine, atropine, and naloxone led to a return of consciousness, and JR was never intubated. In fact, the code sheet reflected that after the naloxone, JR was now fully awake, crying, and complaining of right-sided pain.
JR subsequently complained of nausea and began to vomit. Prior to transferring her to the intensive care unit, the hospitalist placed a nasogastric tube and made JR nil per os. To complete JR’s transfer to the ICU, the hospitalist contacted a critical care attending to give report, and then wrote "holding" ICU admission orders.
JR remained on the regular nursing floor for another hour as the ICU prepared for her arrival. Just prior to leaving the floor, JR’s nurse gave her 13 units of glargine insulin as ordered earlier that afternoon by the attending internist.
JR underwent a standard admission assessment upon her arrival at the ICU. The hospitalist "holding admission orders" included regular blood glucose checks and regular insulin coverage on a sliding scale. At midnight, JR’s blood glucose was over 250 mg/dL, and she was administered 6 units of regular insulin. At 5 a.m., another blood glucose was obtained and was recorded as 114 mg/dL. At 7:45 a.m., the new day shift ICU nurse did a complete assessment and noted that JR was lethargic with slurred speech. The critical care consultant rounded on JR at approximately 10 a.m. and also noted a change in mental status. Thirty minutes later, JR became unresponsive to verbal or tactile stimuli. A point-of-care blood glucose was performed and found to be 10 mg/dL. JR was subsequently intubated, but she never regained consciousness again.
She lived for another 2 months before her family decided to stop her dialysis and she passed away.
Complaint:
The family was upset to learn that JR suffered irreversible brain injury from low blood sugar. JR had been a diabetic on insulin all of her life, and the family couldn’t understand how such a thing could happen under the watchful eye of doctors and nurses.
The complaint alleged that there was an egregious failure with respect to communication between the attending physician, the floor nurse, the hospitalist, and the critical care consultant. Specific to the hospitalist, the complaint alleged that the "holding admission orders" should have included intravenous fluids with dextrose and/or explicit instructions to not give the glargine insulin as ordered earlier that same day.
The complaint was also disparaging of the critical care consultant for not recognizing the hypoglycemia earlier, given the mental status changes that JR exhibited.
Scientific principles:
Hypoglycemia can produce a myriad of neurologic signs and symptoms, but usually presents with symptoms of increased epinephrine release (e.g., tremor, diaphoresis) followed by neurologic symptoms that include generalized seizures, bizarre behavior, coma, and focal deficits. In acute severe hypoglycemia, a bolus of 25-50 grams of dextrose should be administered intravenously, followed by a continuous dextrose infusion. Blood glucose concentrations should be measured hourly. Reversal of neurologic symptoms may lag behind normalization of glucose levels.
Complaint rebuttal and discussion
All the health care providers thought their actions were reasonable in this case.
At the time that the attending internist wrote to resume JR’s glargine and stop the dextrose-containing intravenous fluids, JR was awake and was planning to have a light dinner. The floor nurse who gave the glargine later that night testified that she had a valid order to administer the medication.
