Noticing a trend in CBG and ventricular ectopic beats.

LanceCorpsman

LanceCorpsman

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Female in her 40s with DM2 is admitted to the ICU for DKA. Initial lab tests show that blood sugar was in the 500s and electrolytes were normal.
After taking care of this pt for a few days, I have noticed a trend. Her normal ranges for her CBG was between 250-300 and the pt was in normal sinus. However, whenever the pt's CBG started to get lower, the pt would start having frequent PVCs. As the CBG would lower (100 to 200 mg/dL), pt started to have bigem/trigem and couplets, triplets and progressed to NSVT (<100mg/dL). The waveform below would continue for 20-30 mins until she got something to eat. Whenever the pt was given some sugary foods and the CBG went back up and the pt would return to normal sinus again.
The strip attached is when the sugar dropped to 61 mg/dL (lowest value for this pt). All other lab values were normal with potassium at 4.2 and mags were at 1.9(labs taken when this strip was taken). Although pt is very obese, pt has no other medical Hx other than her diabetes.

There is obviously a trend here, how can hypoglycemia (for this pt at least) affect the heart like this? It's not like the sugars are super low. I just can't see the connection here. The docs really didn't seem to care since they DC'd her a few hours after this strip was recorded.
I asked the all knowing google and had no luck.

What do you guys think is happening?
NSVTHypoglycemia.jpg
 
LanceCorpsman said:
Female in her 40s with DM2 is admitted to the ICU for DKA. Initial lab tests show that blood sugar was in the 500s and electrolytes were normal.
After taking care of this pt for a few days, I have noticed a trend. Her normal ranges for her CBG was between 250-300 and the pt was in normal sinus. However, whenever the pt's CBG started to get lower, the pt would start having frequent PVCs. As the CBG would lower (100 to 200 mg/dL), pt started to have bigem/trigem and couplets, triplets and progressed to NSVT (<100mg/dL). The waveform below would continue for 20-30 mins until she got something to eat. Whenever the pt was given some sugary foods and the CBG went back up and the pt would return to normal sinus again.
The strip attached is when the sugar dropped to 61 mg/dL (lowest value for this pt). All other lab values were normal with potassium at 4.2 and mags were at 1.9(labs taken when this strip was taken). Although pt is very obese, pt has no other medical Hx other than her diabetes.

There is obviously a trend here, how can hypoglycemia (for this pt at least) affect the heart like this? It's not like the sugars are super low. I just can't see the connection here. The docs really didn't seem to care since they DC'd her a few hours after this strip was recorded.
I asked the all knowing google and had no luck.

What do you guys think is happening?View attachment 3148
Click to expand...

My first impression of course would be electrolyte imbalance, but it appears her K+ stayed WNL. There obviously seemed to be an underlying cardiac pathology that seems to be exacerbated by changes in blood glucose. Was the patient discharged with the EKG staying pretty consistent to this? I know that extremely high/low GLU levels can precipitate an MI; I'm assuming a 12-Lead was performed and was unremarkable? Sounds like a cardiology referral is in order. I don't think the high GLU level was "fixing" her heart rhythm, but as you say, her normal was 250-300 mg/dl so her heart may have been sensitive to those rapid swings in blood sugar.

I will have to do some more research, but those are my first impressions in the clinical setting.
 
Was this patient in DKA? I'm asking because you said this patient is a severely (morbidly?) obese DM2. We can go ahead and guess her HA1c was super high with that normal BGL of 300. DM2 patients usually present with higher sugars and HHNK vs DKA which you see more in DM1 patients /new onset. Then again 500 is low but not unheard of for HHS.

Anyway, here is your answer I think:
In these patients with chronically marked baseline hyperglycemia 2* poorly controlled DM2, having their BGL in the "normal range" especially at the low end of normal can present unusual symptoms that might normally be associated with more profound hypoglycemia or hypoglycemia induced stresses. I haven't heard a specific explanation, but I think that is to do with downregulation of membrane transport and cellular machinery to compensate for the "new homeostasis."

Kidney functions, vision, peripheral neuropathies, and peripheral vascular pathologies?
 
RRTMedic said:
My first impression of course would be electrolyte imbalance, but it appears her K+ stayed WNL. There obviously seemed to be an underlying cardiac pathology that seems to be exacerbated by changes in blood glucose. Was the patient discharged with the EKG staying pretty consistent to this? I know that extremely high/low GLU levels can precipitate an MI; I'm assuming a 12-Lead was performed and was unremarkable? Sounds like a cardiology referral is in order. I don't think the high GLU level was "fixing" her heart rhythm, but as you say, her normal was 250-300 mg/dl so her heart may have been sensitive to those rapid swings in blood sugar.

I will have to do some more research, but those are my first impressions in the clinical setting.
Click to expand...

12 Leads were taken, no findings at all. Yeah whenever her glucose would go back to her normal ranges, PVCs would either disappear or have a few here and there.
 
LanceCorpsman said:
12 Leads were taken, no findings at all. Yeah whenever her glucose would go back to her normal ranges, PVCs would either disappear or have a few here and there.
Click to expand...
Just out of curiosity, did the 12 lead(s) confirm these beats to be ventricular in nature, or was it seen as an abberant supraventricular run?
 
Summit said:
Was this patient in DKA? I'm asking because you said this patient is a severely (morbidly?) obese DM2. We can go ahead and guess her HA1c was super high with that normal BGL of 300. DM2 patients usually present with higher sugars and HHNK vs DKA which you see more in DM1 patients /new onset. Then again 500 is low but not unheard of for HHS.

Anyway, here is your answer I think:
In these patients with chronically marked baseline hyperglycemia 2* poorly controlled DM2, having their BGL in the "normal range" especially at the low end of normal can present unusual symptoms that might normally be associated with more profound hypoglycemia or hypoglycemia induced stresses. I haven't heard a specific explanation, but I think that is to do with downregulation of membrane transport and cellular machinery to compensate for the "new homeostasis."

Kidney functions, vision, peripheral neuropathies, and peripheral vascular pathologies?
Click to expand...

I think at this point, her DKA was resolved and she was waiting for discharge. I remember looking at the labs, I didnt notice anything too different. My best guess is similar to yours. Something to do with the membrane transport of the electrolytes being altered by the high BGL. Pt's vision, peripheral neuropathy, and peripheral vascular systems were fine. Her DM2 has done too much damage, yet. I can't say anything about her Kidneys though.
 
VentMonkey said:
Just out of curiosity, did the 12 lead(s) confirm these beats to be ventricular in nature, or was it seen as an abberant supraventricular run?
Click to expand...

12 Lead did confirm it as a ventricular rhythm. 2
 
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