Opinion
LESS IS MORE PERSPECTIVE
Richard K. Bernstein, MD Diabetes Center, Mamaroneck, New York.
Corresponding Author: Richard K. Bernstein, MD, 1160 Greacen Point Rd, Mamaroneck, NY 10543 (diabetes @scientist.com).
More Can Be Life Threatening I have had type 1 diabetes for 67 years and have enjoyed essentially normal blood glucose levels since the availability of the first blood glucose meter in 1969. As a result I do not have the premorbid conditions frequently associated with diabetic patients who undergo surgery. Nevertheless, on entering a hospital I am at great risk for iatrogenic hypoglycemia and ketoacidosis (DKA). About 2 years ago I was scheduled for a minor, 2-hour surgical procedure while under general anesthesia. The hospital was a world-famous institution associated with a major federally funded diabetes center. I had given my surgeon detailed printed instructions for maintenance of my blood glucose level during the perioperative period. He agreed with them and promised they would be followed. The night before surgery I received a telephone call from a nurse telling me that diabetic patients are forbidden from taking basal insulin before surgery. I told her I would end up in DKA and refused to comply. On arrival at the surgical suite I was connected to an infusion of 10% dextrose at a rate of 250 mL per hour. The 2-hour surgery was scheduled for 2 hours later, so by the end of surgery I would have been given 100 g of intravenous (IV) glucose. At my weight, this would raise my blood glucose level by 700 mg/dL, probably putting me into DKA. The likelihood that DKA could cause death in a 78-yearold individual is considerable. I told this to the infusing nurse who replied that it was a hospital rule for all diabetic patients and only the surgeon could issue countermanding orders. He could not be interrupted while in surgery and would not finish for 2 hours. When the nurse left, I clamped off the glucose tubing. During the preoperarative waiting period, I checked my own blood glucose levels. I had been promised a conversation with the anesthesiologist before surgery. She arrived when I was being wheeled into the operating room, glucose tubing still clamped off. When I tried to tell her how to control my
Published Online: April 28, 2014. doi:10.1001/jamainternmed.2014.1229.
858
blood glucose level, she replied that anesthesiologists are not authorized to check patients’ blood glucose levels and that the only nurse in the operating room would be too busy helping the surgeon. Fortunately, I had met another nurse who had treated her diabetic husband following the guidance in a book I had written. We had her paged, and she agreed to check my blood glucose level every 30 minutes. The glucose solution in the clampedoff tubing was finally changed to normal saline, with a “Y” connector for injected glucose if my blood glucose level became too low. As a result of my own interventions, I survived this chain of events without an adverse outcome. I subsequently described my experience to the chief executive officer of the hospital, who replied that this experience was a fluke and could not possibly happen again. He refused to change the rules for future patients. I have heard similar stories from my patients throughout the United States and from at least 6 other countries. The automatic administration of IV glucose to all diabetic patients is not unique to operating suites but is also followed in emergency departments throughout the world. Even the emergency department in the hospital where I work engages in this life-threatening practice. I have taught my patients that in most of the United States, forcing an individual to receive unwanted medications (eg, IV glucose) without a court order is a felony, and a death caused by a felony would be murder. I also inform them that they or their families have a right to immediately speak to the hospital administrator when such a situation arises. For other patients, an addition to the American Diabetes Association treatment guidelines could be of great value. This addition would advocate that diabetic patients in hospitals only be given glucose for blood glucose levels below 75 mg/dL and then only to bring them up to a safer level that the guidelines would specify.
Conflict of Interest Disclosures: None reported.
JAMA Internal Medicine June 2014 Volume 174, Number 6
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archinte.jamanetwork.com/ by a Ndsu Library Periodicals User on 05/28/2015
jamainternalmedicine.com
LESS IS MORE PERSPECTIVE
Richard K. Bernstein, MD Diabetes Center, Mamaroneck, New York.
Corresponding Author: Richard K. Bernstein, MD, 1160 Greacen Point Rd, Mamaroneck, NY 10543 (diabetes @scientist.com).
More Can Be Life Threatening I have had type 1 diabetes for 67 years and have enjoyed essentially normal blood glucose levels since the availability of the first blood glucose meter in 1969. As a result I do not have the premorbid conditions frequently associated with diabetic patients who undergo surgery. Nevertheless, on entering a hospital I am at great risk for iatrogenic hypoglycemia and ketoacidosis (DKA). About 2 years ago I was scheduled for a minor, 2-hour surgical procedure while under general anesthesia. The hospital was a world-famous institution associated with a major federally funded diabetes center. I had given my surgeon detailed printed instructions for maintenance of my blood glucose level during the perioperative period. He agreed with them and promised they would be followed. The night before surgery I received a telephone call from a nurse telling me that diabetic patients are forbidden from taking basal insulin before surgery. I told her I would end up in DKA and refused to comply. On arrival at the surgical suite I was connected to an infusion of 10% dextrose at a rate of 250 mL per hour. The 2-hour surgery was scheduled for 2 hours later, so by the end of surgery I would have been given 100 g of intravenous (IV) glucose. At my weight, this would raise my blood glucose level by 700 mg/dL, probably putting me into DKA. The likelihood that DKA could cause death in a 78-yearold individual is considerable. I told this to the infusing nurse who replied that it was a hospital rule for all diabetic patients and only the surgeon could issue countermanding orders. He could not be interrupted while in surgery and would not finish for 2 hours. When the nurse left, I clamped off the glucose tubing. During the preoperarative waiting period, I checked my own blood glucose levels. I had been promised a conversation with the anesthesiologist before surgery. She arrived when I was being wheeled into the operating room, glucose tubing still clamped off. When I tried to tell her how to control my
Published Online: April 28, 2014. doi:10.1001/jamainternmed.2014.1229.
858
blood glucose level, she replied that anesthesiologists are not authorized to check patients’ blood glucose levels and that the only nurse in the operating room would be too busy helping the surgeon. Fortunately, I had met another nurse who had treated her diabetic husband following the guidance in a book I had written. We had her paged, and she agreed to check my blood glucose level every 30 minutes. The glucose solution in the clampedoff tubing was finally changed to normal saline, with a “Y” connector for injected glucose if my blood glucose level became too low. As a result of my own interventions, I survived this chain of events without an adverse outcome. I subsequently described my experience to the chief executive officer of the hospital, who replied that this experience was a fluke and could not possibly happen again. He refused to change the rules for future patients. I have heard similar stories from my patients throughout the United States and from at least 6 other countries. The automatic administration of IV glucose to all diabetic patients is not unique to operating suites but is also followed in emergency departments throughout the world. Even the emergency department in the hospital where I work engages in this life-threatening practice. I have taught my patients that in most of the United States, forcing an individual to receive unwanted medications (eg, IV glucose) without a court order is a felony, and a death caused by a felony would be murder. I also inform them that they or their families have a right to immediately speak to the hospital administrator when such a situation arises. For other patients, an addition to the American Diabetes Association treatment guidelines could be of great value. This addition would advocate that diabetic patients in hospitals only be given glucose for blood glucose levels below 75 mg/dL and then only to bring them up to a safer level that the guidelines would specify.
Conflict of Interest Disclosures: None reported.
JAMA Internal Medicine June 2014 Volume 174, Number 6
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archinte.jamanetwork.com/ by a Ndsu Library Periodicals User on 05/28/2015
jamainternalmedicine.com
