Endocrine Abstracts

A 71 year lady, who has past history of acute ischaemic stroke ( now bed bound and can only get out of bed with the help of a hoist) , Type 2 diabetes melitus, HTN, CKD and high lipid. She is on Metformin 1 gm twice daily, Ramipril 5 mg at night, Clopidogrel 75 mg od, Atorvastatin 80 mg od. She was brought to hospital by unexplained drowsiness and poor oral intake. Her blood sugar was 72, ketone 5.2, Ph: 7.21, Na: 165, Urea 14 and calculated osmolality of 412. Her chest xray and ct head were unremarkable. Mildly high inflammatory markers. She was showing features of both Diabetic ketoacidosis (DKA) and Hyperglycaemic Hyperosmolar state (HHS). She was initially managed with DKA protocol (fixed rate insulin) with 10 units of Tresiba (basal insulin) cover. Her DKA resolved in 4 hours into the treatment but her Blood sugar remained 37 with an osmolality of 360. Then DKA protocol stopped and she was started on HHS pathway (insulin infusion rate halved) and fluid replacement. Her HHS resolved in 24 hrs time. Her fixed rate of insulin infusion was switched to variable rate and observed for 24 hrs more (she remained on Tresiba 10 units). When her oral intake got better, Her Tresiba and Variable rate stopped and she was started on Novomix-30 bd. She was observed in hospital for 24 hr more and then got discharged back to home. Community nurse referral sent for administration of insulin. It is important to remember that when feature of of DKA and HHS presents together, then to treat DKA first.