Hypoglycemia Case Study Cheshire Medical CenterDartmouthHitchcockKeene Cheshire Medical CenterDartmouthHitchcock Keene is a nonprofit community hospital and clinic whothrough their clinical and service excellence collaboration and compassion for every patient every ID: 577699
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Slide1
Cassandra Reynolds
Hypoglycemia
Case Study Slide2
Cheshire Medical
Center/Dartmouth-Hitchcock/Keene
Cheshire Medical Center/Dartmouth-Hitchcock Keene is a non-profit community hospital and
clinic who—through their clinical and service excellence, collaboration, and compassion for every patient, every time—have a mission to lead the community to become the nation's healthiest 65 average daily censusFounded the Healthy Monadnock 2020 initiativeSlide3
Dietitians at Cheshire
Can work with all medical conditions at
Cheshire Medical Center/Dartmouth-Hitchcock/Keene
Each patient is screened using a malnutrition screening tool and assessed by an RD if at nutritional riskRounding: ICU, medsurg, rehab bedside roundingNutrition consultsSlide4
Patient J
84 year old male
Presented at ER on March 15
th after a fall Head CT negativeFound to have UTI, antibiotics given and sent homeMarch 16th- early AM at homePt found by daughter: flailing in bed, unable to get up, slurred speechEMS arrived, found pt’s blood glucose to be in the 40’sSlide5
Medical history:
A fib, congestive heart failure, cardiomyopathy, COPD, MI, recent surgery to remove a growth on the
ribs (ischemic fasciitis
fibroelastoma), recent falls, UTIRecovering alcoholic, 2 years soberWould drink 6 beers and 2 brandies/dayHistory of smokingPatient not diagnosed with diabetes: A1C of 5.7Slide6
Anthropometrics
Unintentional weight loss
Weight March 2014: 187 #
Weight November 2014: 177# Weight February 2015: 162 #Upon Admission: 157 #16% wt loss in 1 yearHeight: 6’ 2” BMI: 21.9Slide7
Patient history
Lives alone at home, wife widowed
Doesn’t like to cook
Sometimes eats only 1 meal/dayEats frozen meals and daughter brings prepared food for ptReports experiencing spells for 4-6 weeks characterized by cold sweats, racing heart, and hunger. Symptoms will improve when he eats.Slide8
Initial Plan
Hypoglycemia work up:
Labs: Beta
Hydroxybutyrate, C-Peptide, Insulin Level, Urine SulfonylureaAssess regular dietRepeat Head CTAssess blood glucose regularlyConsult EndocrinologySlide9
C-Peptide
is a breakdown product of insulin
Normal
: .05-2.0 nanograms/mLProinsulin is a building block of insulinNormal: 2-6 pmol/LSlide10
Beta
Hydroxybutyrate
is a blood ketone
Normal <.28 mmol/LUrine SulfonylureaCan be useful to assess is hypoglycemia is resulting from exposure to sulfonylurea hypoglycemic drugs (drugs that help the pancreas produce more insulin: glyburide, glipizide)Slide11
Day 2: Endocrinology Consult
CT Scan of abdomen and pelvis negative for mass or adenopathy (swollen lymph nodes)
Differential
causes for hypoglycemiaMalnutritionEndogenous hyperinsulinemiaSlide12
Recommended plan by Endocrinology
Check
serum cortisol level given recent prednisone use for
COPDCortisol and insulin resistance↑Steroids= ↓ ACTH= ↑ Cortisol= ↑Glucose production= ↑Insulin resistance = …. ↑blood glucose
Evaluate
for malnutrition
albumin, pre-albumin,
nutrition
consult
Evaluate
for
insulinoma
Measurement of C-peptide, insulin, proinsulin and serum glucose finger stick when BG <50 and hypoglycemic symptoms presentSlide13
Malnutrition evaluation
Albumin
can be useful to detect malnutrition but can also be influenced by dehydration, liver disease, infection, nephritic syndrome, post-op, edema and
over hydrationPre-albumin shorter half life: can be influenced by chronic renal failure, acute catabolic states, post surgery, liver disease, infection and dialysis **Cannot diagnose with only these labsSlide14
Day 2 Nutrition Consult
Requested by MD to assess what patient is eating at home
Diet recall revealed 1600-1800 daily kcal intake
Some swallowing difficulty with pills: swallowing evaluation requestedPatient feels he has lost weight in the last 2 years because he quit drinking beerPatient needsCalories: 1927 (REE x 1.3, using miflin equation)Protein: 72 grams (1 gram/kg)Slide15
Nutrition related lab values
Albumin: 2.8 g/
dL
(low)Calcium: 8.5 mg/dL (low)Potassium: 3.2 mmol/L (low)Creatinine: 0.7 mg/dL (low)Slide16
PES Statement
P:
Inadequate energy and protein intake
Swallowing difficulty (modified barium swallow requested)Altered nutrition related lab valuesUnderweightInvoluntary weight lossE: Inadequate PO intake of kcals to prevent weight lossS: Muscle mass loss, unintentional weight loss, subcutaneous fat lossSlide17
My PES
Altered nutrition related lab
values (r/t) malnutrition or
insulinoma (aeb) frequent hypoglycemic episodesSlide18
Intervention
Patient diagnosed with “non-severe malnutrition”
Plan:
Begin sending HS Ensure Calorie counts initiatedCalorie counts found pt to be eating 2500-3000 kcals/day while inpatientPatient states he’s eating more here than at homeContinues to decline in weightSlide19
Glucose while in hospital
Patient continued to experience very low blood sugars
ranging anywhere from 30-70 mg/
dL. Usually between 12 AM and 7 AMNormal blood sugars during the day 100-165 mg/dL on averageNight shift neglected to draw blood prior to treatment of hypoglycemiaSlide20
Day 5 Nutrition follow up
Patients weight showed an 10# increase from yesterday.156.6# on 3/19 to 166.7# on 3/20.
Spoke
with the patient to see if he felt he was retaining fluid and he stated he did not, no obvious signs of edema notedQuestion of weight accuracy.Patient has switched from thick liquids to regular and he feels he is doing ok with that switch.Has been drinking both of the ensures sent to him.States he has been eating really well. Will d/c calorie counts.Will continue to monitor weight.Blood glucose levels are more steady, only dipping to 82 throughout the night.
F/U
on glucose monitoring.
Continue
Regular diet, Ensure HS and once with breakfastSlide21
Day 6
Awaiting
insulinoma
work upHospitalist medical chart documentation:“Non-Severe malnutrition with associated weight loss [as] likely cause of hypoglycemia with decreased protein and decreased albumin”Protein: 4.8 g/dL (normal 6.6-8.7)Albumin: 2.3 g/dL (normal 3.5-5.2)Most recent low BS: 54 mg/dL on 3/21 at 0426 Ensure at bedtime but 0200 BS’s still low, Ensure ordered for 0200Slide22
Day 6 Nutrition Follow up
Eating well. Pt weight increased up from 166# to 171#
3/21 glucose: 54 at 0426, 3/23: glucose: 106 at 04:51.
2 AM snack initiated this morning. Per MD, patients lab work has all been reviewed and the issue with hypoglycemia is attributed to his decreased nutrition PTA. Discussed with patient the need for HS and 2 AM Ensure supplements, he is not able to say he will do this after discharge. Need to speak with patient's family about need for snacks/supplements.Slide23
Day 7
Patient experiencing hallucinations
Insulinoma
labs reviewed **** Blood drawn when BS >50C-peptide: 2.43 ng/mL (normal)Insulin: 4.1 mmol/L (normal)Cortisol: 13.77 nmol/L (normal)Beta-hydroxybutyrate 0.08 mmol/L(normal)Slide24
Day 8 Endocrinologist F/U
“Thus far there has been no documented serum glucose <55 and therefore haven’t evaluated for endogenous insulin production. However, since point of care glucose currently 61 we will send insulin, pro-insulin, C-peptide and serum glucose now. Certainly if insulin levels are high in the setting of relatively low serum glucose we will have reason to more aggressively pursue this diagnosis.”
Test results: C-Peptide and B-
hydroxybutyrate high, insulin normalSlide25
Day 9
Hospitalist medical chart documentation
“Repeat tests done but serum glucose level was not low so the value may be nil. Etiology still unclear and therefore a management plan that doesn’t include close monitoring may be difficult to envision.” Slide26
Day 9 Nutrition follow up
Patients blood sugar continues to drop in the early morning, this morning going down to 55 at 0600. He was given 4 pieces of toast, orange juice and ensure which brought his blood sugar up to 71 at 0645.
Asked his nurse if he has been drinking the 0200 Ensure but that was unknown.
Patient ate 100% of dinner on 3/24 and >50% of HS snack: ensure and ice cream.Will continue to f/u on 0200 Ensure. Currently he is being sent 3 Ensure supplements, one at 10 AM one at HS and another at 0200. Slide27
Day 10
Hospitalist medical chart documentation
“Serum glucose level this AM was 44 but no insulin workup sent by RN responsible for him.”
“I think that if we fail to obtain a dx for the hypoglycemia we will need an effective means of managing it before he could be sent home safely”Slide28
Day 11
Endocrinologist suggests
Diazoxide
every 8 hours.Will be available in 3 days (Monday)Resend Insulin, Pro-Insulin, C-Peptide, and B-HyrdoxybutyrateSlide29
Diazoxide
Originally invented as a non-diuretic hypotensive agent
Found to have a hypoglycemic effect
“Diazoxide is primarily indicated for the treatment of severe hypertension (particularly when associated with renal disease) and chronic intractable hypoglycemia occurring, for instance, in the context of an insulinoma.”Works by slowing insulin release from the pancreasSlide30
Day 11 Nutrition follow up
3/27:Glucose:56-low
Weight 166#, remaining fairly stable
Patient was NPO this morning, has not eaten yet, appetite is so, so. Patient reports he has been drinking the Ensures at HS but maybe not at 2 AM. He is planned to start Diazoxide on Monday for hypoglycemia. Hopefully this will help with early morning hypoglycemia which is still a problem. Will continue with supplements, follow PO intake, weight, labs and progress.Slide31
Day 13
Medical Chart documentation:
Suspect glycogen depletion as reason for hypoglycemia
Plan: Long discussion for treatment of hypoglycemiaGlucose tablets followed by CHO plus protein or milkSlide32
Day 15
Medical Chart Documentation:
Started
Diazoxide yesterday at 1 pmSince then BS’s: 54 (this AM), 124, 81Continue meal plan of frequent snacks, ensure and “rescue” planSlide33
Blood Sugars on
Diazoxide
3/30
811243/3154
93
89
112 *
Diazoxide
increased to 100 mg
4/1
93
108
134
97Slide34
Day 16 Endocrine follow up
“
Diagnosing endogenous
hyperinsulinema has proven difficult. Simultaneous C-Peptide, Insulin, Pro-insulin and B-Hydroxybutyrate finally sent yesterday when serum glucose was 50 (7:50 AM 3/30). Results: C-Pep 2.05 ng/mL (elevated) Insulin 2.7 mmol/L (normal)Pro-insulin and B-hydroxybutyrate pendingSlide35
Endocrine assessment/plan
Given the patients overall frail health status and probable high surgical risk, further imaging or invasive testing to evaluate for
insulinoma
is probably not indicatedPlan: Continue Diazoxide as needed and tolerated to eliminate hypoglycemic events. Careful meal planning (and hypoglycemia protocol) will be needed on discharge.Slide36
Day 18 Nutrition follow up
Glucoses: 105, 159, 127, 95 ,115
Meds include:
DiazoxizideDiscussed fasting hypoglycemia with patient. We discussed the need for high kcal foods in order for patient to maintain weight. Patient is looking forward to his large bowl of ice cream before bedtime at home.Phone number of RD office given to patient. Available for questions. Slide37
Day 22 Discharge
Patient discharged to SNF on April 7
th
Discharge diagnosisHypoglycemia with question of increased endogenous insulin productionDischarged on regular diet with small frequent meals, and to watch blood sugar closely. Slide38
Discussion points…
Do we agree with the diagnosis?
Malnutrition
severity?Insulinoma r/t growth on ribs?Weight changes:16.5 # range Day 1:
157.5
Day 2:
160.9
Day 3:
157.6
Day 4:
156.6
Day 5:
**166.7
Day 6:
**171.3
Day
7:
174
Day 8:
173
Day 9:
174
Day 10:
**168
Day 11:
167
Day 12:
166
Day 13:
167
Day 14:
165
Day 15:
166
Day 16:
163.9
Day
17:
165.8
Day 18:
166.2
Day
19:
165.2
Day 20:
**170.8
Day 21:
170.3
Day 22:
173.3Slide39
Resources
Mahan, L. K.,
Escott
-Stump, S., Raymond, J. L., & Krause, M. V. (2012). Krause's food & the nutrition care process (13th ed.). St. Louis, Mo.: Elsevier/Saunders.Academy of Nutrition and Dietetics. Nutrition Care Manual. http://www.nutritioncaremanual.org. Accessed May, 2015http://www.nlm.nih.gov/medlineplus/ency/article/000387.htmhttp://www.uthsc.edu/endocrinology/documents/DM_Hypo/Insulinoma.pdfLabtestsonline.org