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hypoglicemia en end of life

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JOURNAL OF PALLIATIVE MEDICINE
Volume XX, Number XX, 2016
ª Mary Ann Liebert, Inc.
DOI: 10.1089/jpm.2016.0144
Letter to the Editor
Refractory Hypoglycemia at the End of Life
Treated with Continuous Dextrose Infusion
through Ambulatory Infusion Pump
Benjamin T. Galen, MD, FACP
Dear Editor:
A 55-year-old woman originally from Trinidad and Tobago
was admitted to the medicine service with abdominal pain,
weakness, hematuria, and severe hypoglycemia: her presenting
capillary blood glucose was 30 mg/dL. She had a six-year
history of metastatic KRAS-mutant colon cancer, which had
been treated with multiple chemotherapy regimens. She had
recently experienced progression of pulmonary, hepatic, and
retroperitoneal disease while considering trial enrollment. A
previously placed percutaneous nephrostomy tube was exchanged, and symptomatic anemia was treated with red blood
cell transfusion. Her pain was managed successfully with
standing methadone and breakthrough hydromorphone. Hypoglycemia, which was likely due to anorexia, cachexia, impaired gluconeogenesis, and tumor metabolism, initially
responded to intravenous D50W and oral glucose tablets.
In discussion with palliative care, the patient decided that
treating cancer was no longer her priority and the consulting
oncology team agreed with supportive care and symptom management, especially given decline in ECOG performance status
from 3 to 4. The patient’s primary goal became returning to
Trinidad from New York City to be with her extended family and
continue comfort care there. The main barrier to her achieving
this goal was the development of severe, recurrent hypoglycemia.
Her blood glucose dropped as low as 19 mg/dL on the morning of
hospital day 9. Although she was not consistently symptomatic at
glucose levels below 40 mg/dL, repeat D50W boluses and
eventually continuous infusion of dextrose-containing fluids
through preexisting portacath were necessary. Despite increased
doses of oral glucose tablets, liberalization of diet, and even the
addition of oral dexamethasone, the patient could not be weaned
off of intravenous D10W at a rate of 50 mL/hour (5 g/hour).
Given her heroic goal of returning to Trinidad before she
died, the decision was made to pursue continuous home
dextrose infusion. Airline travel and necessity of high dextrose would require an ambulatory infusion pump as opposed
to gravity infusion. Candidacy for this palliative intervention
required several key factors. A home infusion company
compassionately loaned a CADD-prizm ambulatory infusion pump while the family arranged the funds to purchase
this device (approximate cost of $2,500). The family was also
able to pay for a supply of D10W bags and intravenous tubing.
The patient’s sister, a pharmacist by training, was taught how
to replace completed D10W bags. The family arranged for
medical follow-up in Trinidad to provide glucose monitoring
as well as portacath access and dressing changes. The infusion
pump was programmed before discharge and the patient took
a commercial airline flight with accompaniment to Trinidad.
She was comfortable and successfully maintaining home
D10W infusion as of one-week post-hospital discharge.
Hypoglycemia is not an uncommon issue for terminally ill
patients. Treatment options include ‘‘corrective’’ strategies
as well as supportive care focused on relieving the symptoms
of hypoglycemia.1 Although artificial nutrition and hydration
typically have a limited role for symptom management,
quality of life, or survival at the end of life, personal values
and individual goals are paramount.2 The decision to pursue
continuous ambulatory infusion of dextrose solutions at the
end of life should include careful consideration of the risks
and feasibility of this heroic intervention if it is necessary to
achieve a dying patient’s goals.
Acknowledgments
The author would like to thank Theo Okonkwo, RN, and
Option Care infusion services for making this patient’s endof-life goals achievable.
References
1. Gonzalez F, Roshan R, Levene R: Hypoglycemia management in nondiabetic adults at the end of life. J Palliat Med
2015;18:552–553.
2. Blinderman CD, Billings JA: Comfort care for patients dying
in the hospital. N Engl J Med 2015;373:2549–2561.
Address correspondence to:
Benjamin T. Galen, MD, FACP
Montefiore Medical Center
and Albert Einstein College of Medicine
Weiler Division
Suite 2-76
1825 Eastchester Road
Bronx, NY 10461
E-mail: bgalen@montefiore.org
Department of Medicine, Division of Hospital Medicine, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York.
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