HYPERGLYCEMIC CRISIS AND COVID-19 AT CROSSROADS

Abstract

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Diabetic Ketoacidosis (DKA) & Hyperosmolar Hyperglycemic State (HHS) are known complications of Diabetes Mellitus and a common cause of hospitalization. In patients admitted to the hospital for DKA, routine practice is to screen for source of infection as a trigger of the hyperglycaemic state. Although workup and medical management of patients presenting with DKA/HHS has been standardized, the COVID-19 pandemic has brought on new challenges to consider. This case will highlight these considerations and dissect the dichotomy in treatment of patients with DKA/HHS and co-existing COVID-19 pneumonia. CASE PRESENTATION: An 83 y/o female with Insulin-dependent Diabetes Mellitus presents with lethargy and fatigue. On admission, she was normotensive with elevated HR/RR, saturating 90% on RA and T-max of 99.9. Lab-work showed glucose of 726, High Anion-Gap Metabolic Acidosis, PH of 7.3 on ABGs, leukocytosis and high serum ketones. Although SIRS criteria were present on admission, it was thought to be confounded by presence of DKA. Per protocol, cardiovascular emergencies and non-compliance were ruled out prior to infectious workup. U/A was unremarkable while CXR showed B/L ground-glass opacities. Due to presentation during the SARS-CoV-2 pandemic, patient underwent viral PCR screening and tested positive. She was admitted to ICU and started on IV Insulin & IV fluid hydration for DKA. BMP was done Q4-6hrs to address metabolic disturbances while reducing exposure for medical staff. She was successfully transitioned to Sub-Q Insulin. corticosteroids were avoided to prevent worsening hyperglycemia. IV fluids were discontinued upon initiation of po intake. Patient was discharged in stable condition, without worsening respiratory status. DISCUSSION: Infection is one of the most common culprits of hyperglycemic crisis in diabetic patients. During the COVID-19 pandemic, screening for this viral infection is imperative to guide clinical decision making. As clinical studies have emerged, some guidelines now suggest Sub-Q insulin therapy in place of IV Insulin in order to reduce the need for monitoring and exposure of health-care workers. Treatments of these diseases are contradictory. In hyperglycemic state, IVF plays a crucial role in reducing mortality while in COVID-19 pneumonia, it has the potential to worsen respiratory status. On the other hand, use of corticosteroids in COVID-19 infection is fundamental to reduce the burden of systemic inflammation, while it may cause worsening glycemic status in uncontrolled diabetes mellitus. CONCLUSIONS: Routine infectious screening during a pandemic must include testing for COVID-19. Decision regarding IV fluid hydration, initiation of corticosteroids, and type of insulin therapy should be done on case-to-case basis. Further studies, scoring criteria, and consideration of other co-morbidities may help guide clinical management of these two pathologies side by side. REFERENCE #1: Francisco J. Pasquel, MD. "Diabetic Ketoacidosis Among Patients Hospitalized With or Without COVID-19." JAMA Network Open, JAMA Network, 10 Mar. 2021, jamanetwork.com/journals/jamanetworkopen/fullarticle/2777312. REFERENCE #2: Rao, Sanjana et al. "Diabetic ketoacidosis in patients with COVID-19." The American Journal of the Medical Sciences, 25 Nov. 2020, doi:10.1016/j.amjms.2020.11.027 REFERENCE #3: "Inpatient Insulin Protocols - COVID-19." Inpatient Insulin Protocols - COVID-19 | American Diabetes Association, professional.diabetes.org/content-page/inpatient-insulin-protocols-covid-19. DISCLOSURES: No relevant relationships by Padmini Giri, source=Web Response No relevant relationships by Victoria Gonzalez, source=Web Response No relevant relationships by Sourabh Sourabh, source=Web Response No relevant relationships by DANYAL TAHERI ABKOUH, source=Web Response