Friday, August 2, 2013

"Blood glucose over 1000!!!"

Ok so it's more impressive using mg/dl, but using SI units, it's actually 67 mmol/L. But still very high!!

This was the case we discussed in morning report today.

An elderly patient who was sent in to the ER by their family doctor due to an elevated blood glucose.

Context is everything and if this were a young patient or a patient with the right 'metabolic' characteristics we would think of a first presentation of T1DM or T2DM respectively.

However, this patient has no history of diabetes and in fact routine physical as recent as 2012 revealed a normal fasting blood glucose.

Already this patient dose not fit the right picture for a new diagnosis of T2DM and so we discussed the most likely explanation for this patient, and decided at some point, we would like to investigate the pancreas (malignancy?).

We went through the exercise of anticipating his symptoms as a result of his hyperglycemia, and predicted correctly so, that he would have lethargy, fatigue, polyuria/polydipsia, decreased appetite, weight loss, abdominal pain, nausea/vomiting, blurry vision, paraesthesias, and also considered mental status changes (which were absent).

His physical examination revealed a mild postrual drop, but more importantly he was symptomatic from supine to standing, and his JVP was flat all pointing to volume contraction.
He was also icteric, with no abdominal findings that further supported our initial thoughts.

Lab investigations revealed a serum glucose of 67, no anion gap, normal electrolytes (inlcluding a K of 5.0). Ketones were negative.

HHS (Hyperglycemic Hyperosmolar State)

Differs from DKA in that DKA is an absolute insulin deficiency that is associated with ketosis.
HHS is a relative insulin deficiency that can be associated with ketosis (hence the change to HHS from HONK)

General principles of treatment (not inclusive)

1. Hyperglycemia requires FLUIDS 
2. Acidemia requires insulin

3. Watch the K as insulin will shift and lower. 

Flow charts are key in charting fluids, BG, insulin, AG, Na, K, HCO3.

Back to the case. This patient require 8 L of fluid overnight, received insulin therapy and within 24 hours his blood glucose had normalized and he was euvolemic.

BUT, bili was 90, his liver enzymes were elevated consistent with obstruction, and a CT revealed a pancreatic mass.

His diagnosis is likely to be pancreatic CA and is going for ERCP for decompression and biopsy.

See this 'classic' CMAJ article on the diagnosis and treatment of DKA and HHS.

Also check out  the JAMA RCE on hypovolemia

1 comment:

  1. Interesting case, thanks for posting.