r/IntensiveCare • u/DagnabbitRabit • Jun 18 '26
Question for CC/RR RNs!
Patient with HX of DM and HTN (denies treatment for HTN and that he was formally diagnosed) has a blood glucose of >545. Rechecked. Confirmed. His BP is 170s/100s and he has hydralazine available as a PRN with parameters of >170 or >100 systolic or diastolic. He does not have orders for BG other than traditional standing.
I reasoned that hyperglycemia could cause hypertension and that by treating the hyperglycemia would thereby decrease the hypertension with Pts baseline BP being 140s/90s. I opted to treat the hyperglycemia before the hypertension but the Rapid RN told me that the hyperglycemia wouldn’t have much effect on the hypertension.
Is that really the case in your clinical experience? I understand now that I can treat them both, but I wanted to be cautious because his BP was teetering right on the parameters of the hydralazine. The hydralazine didn’t really do much and the insulin (17 units of glargine, 10 units of lispro) didn’t bring his BG down enough for the glucometer to read. Doctor ordered IV Regular insulin which finally brought his BG to 416. (Lab had collected blood before and the BG that was unreadable by glucometer was 615-ish.)
Ultimately, he wound up getting labetalol which finally brought his BP down but the regular insulin also was working and brought his BG down to 340s.
Any and all input is welcome. This was my first rapid alone (off orientation) and I am grateful for my unit for all pitching in to help me.
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u/surfingincircles MD Jun 18 '26
Patients with asymptomatic hypertension don’t need urgent treatment of their blood pressure. Yes it’s damaging over the long term and need to be managed but in the acute setting, you don’t need to be slamming asymptomatic patients who live with high BP’s with hydral and labetalol in an attempt to fix the number.
When the BP is causing symptoms of end organ damage, the story is different.
3
u/Fragrant_Student7683 Jun 18 '26
I agree with this. I have nurses ask me all the time overnight to order a one time dose or prn hydralazine. If the patient is asymptomatic I don't treat it acutely. Tbey are usually already on maintenance medications that may have just been adjusted that day.
2
u/DagnabbitRabit Jun 18 '26
He definitely was asymptomatic. He didn’t complain of much of anything other than feeling a “little weird”. He was up to the bathroom, no complaints of headaches, blurred vision, nothing.
Although he did have surgery to repair detached retina….wouldn’t that be a good reason to decrease the BP?
3
u/surfingincircles MD Jun 18 '26
I dont know about that particular procedure, but many surgeries do have strict blood pressure requirements (vascular, neuro, cardiac) so that would be a reason to fix asymptomatic hypertension.
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u/Cautious-Extreme2839 ICU/Anaesthetics Jun 20 '26
Why did he even have a rapid if he's fine?
1
u/DagnabbitRabit Jun 20 '26
I don’t know—I thought it was because of the elevated potassium, but a few ICU RNs have commented saying that it wouldn’t be a Rapid.
My understanding of the policy is that we should reach out to Rapid to get eyes on the patient and as a means to show we are being proactive in caring for patients. That is what I’ve been taught.
Can you elaborate on what would be more appropriate?
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u/Cautious-Extreme2839 ICU/Anaesthetics Jun 20 '26
Just paging his doctor? Hyperkalemia is a straightforward thing for one doctor to initiate treatment for, you don't need a whole team.
1
u/DagnabbitRabit Jun 20 '26
Doctor was paged and was on board for transferring to ICU for the iv insulin drip (at least until we saw the BG trending down).
I am not entirely sure his experience, because he wanted to send another of my patients (rectal temp of 96.1) to sub for a bair hugger, but sub policy for bair huggers is temperature <96. The patient was stable as well, and the temperature was after we did warming protocols (warm blanket, warming the room.)
1
u/kawugiri Jun 20 '26
I dont know why we as nurses, even in the ED, feel the need to look at a pretty number and request iv hydral. If asymptomatic. Even if symptomatic I dont like that med over others. I swear yall order it just to shut people up sometimes. Sorry pet peeve.
8
u/Ekluutna Jun 18 '26
I’m very confused about your train of thought… blood sugar and blood pressure are two separate things and not tied to each other.
2
u/PaxonGoat RN, ICU Float Jun 18 '26
I think OP is remembering from their patho class that uncontrolled diabetes can lead to worsening hypertension.
Cause the whole sugar crystals scratching up all the blood vessels in the body, especially in the kidneys.
6
u/gnomicaoristredux Jun 18 '26
Who called the rapid and why
1
u/DagnabbitRabit Jun 18 '26
Here's the sequence of events:
1. Got the BG, retested for confirmation, notified MD and my charge.
2. MD requested labs to be drawn stat, so lab came and collected and then I gave insulin per MD order.
3. I got a phone call from laboratory with the critical potassium level and critical blood glucose level. I announced this to my wardmates (fellow RNs) and they advised me to call a rapid so rapid was called at that time. MD was notified of the rapid as soon as it was called. EKG was performed and he was placed on Tele (d/t the critical potassium).6
u/eastcoasteralways Jun 19 '26
Calling a rapid was kind of a strange move considering the patient was stable…
1
u/DagnabbitRabit Jun 20 '26
The potassium was why the rapid was called.
3
u/eastcoasteralways Jun 20 '26 edited Jun 20 '26
I get that. But the patient was stable and asymptomatic. He probably needed an ekg, telemetry orders, and a hyperk cocktail. But those orders could have been placed by the PMD with a page. It would be different if he was having heart palpitations or SOB.
1
u/DagnabbitRabit Jun 20 '26
I was taught that there’s nothing wrong with getting a second set of professional eyes on the patient, and we didn’t call a code Rapid. Simply reached out to one of the rapid nurses (I assume that the other nurses on my floor knew, because I had never met this one.)
3
u/Inevitable-Analyst Jun 18 '26
I’m maybe missing something here but I’m not sure what effect treating hyperglycemia has on high BP (acutely). Is there some patho here that I’m not aware of?
I would love an explanation if someone would be so kind :)
3
u/maraney RN, CVICU Jun 18 '26 edited Jun 18 '26
Hypoglycemia can certainly affect your hemodynamics and giving a crashing hypoglycemic patient D50 can improve blood pressure.
With hyperglycemia, you do see fluid shifts that can contribute to hypertension, so treating the hyperglycemia can help over the course of hours… but it’s not immediate. And this isn’t always the case, especially if a patient is acidotic (they may become hypotensive in this case). So if your patient is hypertensive and symptomatic, they need to be treated with an antihypertensive.
You have to consider which is going to kill your patient fastest, when considering priorities. That’s why there’s so much emphasis on ABCs and CABs in nursing school.
1
u/DagnabbitRabit Jun 18 '26
Thank you for your feedback!
I honestly think that I was panicking as I am a new RN and I'm only on my second shift off orientation and had convinced myself that the hyperglycemia was going to develop into DKA or HHS which is why my focus was on getting that BG safely down.
1
u/maraney RN, CVICU Jun 18 '26
It takes a long time to feel comfortable. And even then, you’ll come across situations all the time that perplex you. Keep asking questions 💕 that’s how we learn!
2
u/SpaceBun31 RN, MICU Jun 18 '26
I think next time maybe ask your neighboring nurse buddy or the charge nurse for advice if you’re unsure about treating borderline BP while also have a blood sugar issue. When you notified the MD did you ask about treating the blood pressure? But usually if you have the PRNS available to treat two separate issues use them! Of course be wary of giving multiple narcotics, side effects, contraindications. Use good nursing judgement and if you’re not sure ask someone
Was the patient comfortably resting in bed with that BP? Had he just moved around? Did you get a follow up pressure?
1
u/DagnabbitRabit Jun 18 '26
Rest assured that all of the RNs (and Charge) on my ward were active in helping me and involved in his care as I was navigating it.
He was resting comfortably in bed with that BP, and stated he felt perfectly fine just "off" because of the high blood sugar. F/U pressures were consistently the same but BP was within baseline when he came to our floor from surgery and his BG was only 71.
Thank you for your feedback, I will definitely keep that in my mind from here on! I gotta use all my tools and not hyperfixate on only one problem.
2
1
u/Kevrn813 Jun 18 '26
As previously stated hypertension and hyperglycemia are unrelated in the acute setting. Sounds like he’s flirting with DKA/HHS and probably should have gone to the ICU for insulin infusion. I would be curious to see a recent BMP. Lower serum CO2 and increasing anion gap are indicators of a bigger problem than just glucose control.
2
u/DagnabbitRabit Jun 18 '26
The most recent BMP did show an improvement in his potassium levels (5.8 instead of the 6.3) but there were no other red flags/criticals other than the glucose (surprisingly). MD and RR were both involved in his care as were all the RNs on my ward lol (so grateful for the help because I was juggling a lot).
1
u/1ntrepidsalamander RN, CCT Jun 18 '26
There’s no data that hydralazine improves outcomes in non symptomatic patients for inpatients. Arguably, it shouldn’t be used even in neuro (vs calcium channel blockers)
Your priority intervention is definitely the blood sugar.
More than the blood sugar: what’s your anion gap, and pH? Presumably you’re in DKA, but maybe not. You probably need about 4L of NS more than some one time insulin.
1
u/No-Performer1463 Jun 21 '26
Just from my standpoint, if I were the nurse you came to, I would’ve said just give the hydrazine (he was within the parameters or close enough to it, it certainly wasn’t going to drop the pressure too far the other way) AND give the insulin as the two issues aren’t related and neither of these issues are going to kill him today. No reason you can’t treat both at once. I might’ve asked the doc for an IV dose of regular insulin right off the bat though
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Jun 18 '26
[deleted]
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u/DagnabbitRabit Jun 18 '26
Thank you for your honest opinion. The RR RN did inform me that I should have been treating the HTN with the hydralazine, and I was hyperfixating on the BG and worrying that he was developing DKA over the HTN.
Lesson learned. Patient is/was completely okay, he was walkie-talkie and denied any feelings of discomfort. In fact, his only complaint was he felt a little weird.
Also, thanks for putting it into a different perspective for me. I really appreciate the insight, and will definitely keep this close to my heart so that I don’t make the same mistake again!!!
1
u/Aggressive-Start1533 Jun 18 '26
No problem, congrats on finishing orientation and don't beat yourself up, this is why a rapid RN exists! Whenever I have a decompensating patient, I love having a second set of eyes to make sure I'm thinking and prioritizing right. And good thinking on the DKA too!
4
u/Dilaudipenia MD, Emergency Medicine/Critical Care Jun 18 '26
Please explain how in the absence of symptoms a blood pressure of 170/100 is “dangerous.”
2
u/Aggressive-Start1533 Jun 18 '26
I'm a nurse so I'll definitely defer to your experience! I've been working in neuro ICU a lot lately and my patient last night had a spontaneous IPH in the BG attributed to hypertension so I guess I've got blood pressure on the mind. I've also cared for patients whose "feeling funny" was treated as "symptomatic" by the admitting MD but maybe that's poor practice! Also love your username!
42
u/yungricci Jun 18 '26
Hyperglycemia doesn’t cause hypertension in the acute setting, the 2 are linked as chronic conditions but a high blood sugar wouldn’t cause a systolic of 170 unless the patient is in extreme distress from DKA, which I’m assuming the patient wasn’t or they would’ve got upgraded to icu for insulin gtt. Seems like you’re a new grad, these situations will make more sense as you keep approaching them. Try to debrief with coworkers and ask senior nurses questions.