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  • Dr Luke Phillips

FAST FRIDAY #1 – 'High' BSL in a Type 2 Diabetic

Updated: Apr 7

Dr Luke Phillips Emergency Physician

Peer review: Dr David McCreary


Welcome to Fast Fridays – a case-based, rapid review of a topic. The cases have been adapted from real patients but have been changed for anonymity and to emphasise key learning points.


THE CASE

An 84-year-old presents with a 4-day history of cough, shortness of breath and some fevers/lethargy. Family report that they have had decreased oral intake throughout that time and have had polyuria. They have a history of Type 2 DM (insulin-requiring) and their BSL is reading “high”.


BASED ON THE ABOVE, WHAT DO YOU THINK IS HAPPENING?

I am concerned that this patient has a developing or established hyperglycaemic hyperosmolar state (HHS) that is likely precipitated by chest sepsis (or COVID... it is 2022).

I need to look for other precipitants of a HHS such as a myocardial infarction, surgical/GI issue that leads to excessive vomiting, evidence of stroke or intracranial pathology, any recent steroid use or compliance/changes with medications. 


I WISH IT WAS STILL CALLED HONK, BUT WHAT IS HHS?

HHS is characterised by hypovolaemia, hyperglycaemia (>30mmol/L), mild or absent ketonaemia (Ketones < 3mmol) and a high osmolality (>320mOsm/kg).


It differs from DKA due to its insidious onset and its pathophysiology is caused by a combination of reduced ability to utilise glucose and a disease state causing elevated counter-regulatory hormones (aggh – primary exams 🤯) leading to gluconeogenesis and glycogenolysis. The result is hyperglycaemia and an osmotic diuresis.


You send some bloods. A formal glucose (it came with a bowtie 🤵‍♂️) is 40mmol/L and blood ketones are 2 mmol/L. Your venous blood gas is outlined below.