Effects of Hyperglycemia on Neurologic Outcome in Stroke Patients

Alison S. Paolino; Krista M. Garner

Disclosures

J Neurosci Nurs. 2005;37(3):130-135. 

In This Article

Abstract and Case Study

Abstract

Hyperglycemia in acute stroke patients increases cerebral infarct size and worsens neurologic outcome with and without preexisting diabetes mellitus. Hyperglycemia results from metabolic alterations in glucose metabolism, and is most common in patients with acute illness such as stroke. Strict control of hyperglycemia with intensive insulin therapy has been shown to dramatically decrease hospital morbidity and mortality, inpatient stays, hospital costs, and, most importantly, neurologic injury. Insulin treatment protocols developed and implemented by multidisciplinary teams allow for rapid and effective control of hyperglycemia. Nurses who know about hyperglycemia's often-neglected and detrimental effects can play a vital role in influencing outcomes in stroke patients.

Case Study

A 67-year-old woman presented to the emergency department with an acute onset of left arm weakness and difficulty with walking and speech. Her medical history was significant for hypertension and cardiovascular disease. A physical exam revealed a blood pressure of 194/108 mm Hg, dysarthric speech, and decreased strength in the left upper and lower extremities. Laboratory values revealed mild electrolyte abnormalities and an elevated serum glucose of 268 mg/dL. Computed tomography (CT) of the head demonstrated early findings consistent with acute ischemic stroke.

The woman was admitted to the neuroscience intensive care unit (ICU) for acute stroke care and a diagnostic work-up. She was placed on standard stroke protocol admission orders, with bedside fingerstick glucose monitoring every 6 hours. A sliding-scale regular insulin regimen also was in place to treat blood glucose higher than 150 mg/dL, as needed. Throughout the evening of admission and the following day, her blood glucose level remained higher than 200 mg/dL despite sliding-scale coverage. A hemoglobin A1C was ordered to check for diabetes mellitus (DM). No changes were made in the sliding scale or monitoring frequency.

On day 2 after admission, the patient's neurologic status declined further. A clinical exam revealed forced eye deviation, left-sided paralysis, and declining mental status. She required intubation and full mechanical support for severe aspiration pneumonia.

Magnetic resonance imaging (MRI) of the brain revealed an evolving large ischemic stroke in the right middle cerebral artery distribution with significant brain edema. She eventually required tracheostomy and gastrostromy tube placements for long-term management because of her poor neurologic condition. She was discharged to a skilled nursing home after 1 month of hospitalization.

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