Hyperglycaemia

You are the urology CT1 who is asked to review a 60 lady who is day 4 post left nephrectomy. She is spiking temperatures and the nurse is concerned that her bedside blood glucose level is 20. She is an insulin dependent diabetic.

Example answer introduction

In this scenario, in a patient who is diabetic with a high blood glucose I would be concerned of possible diabetic ketoacidosis which may be precipitated by an infection, given that the patient is spiking temperatures.  I would recognise that this is an emergency and attend immediately. I would assess this patient using an A-E approach according to the CCRISP algorithm followed by a focused history and examination. I would arrange further investigations to confirm my diagnosis depending on my clinical suspicions and escalate to the general surgery registrar.

Initial Assessment and Simultaneous Resuscitation

 

On arrival, manage the patient using an A to E approach according to the Advance Life Support algorithm.

  • Airway 

  • Breathing - check oxygen saturations, respiratory rate, listen to chest, assess work of breathing, breathing depth - if concerns  give high flow oxygen 

  • Circulation

    • Pulse, Blood pressure, capillary refill time, mucus membranes, skin turgor, fluid input/output, catheter is septic

    • IV access - large bore and bloods including CRP

    • Give fluid challenge of 250ml crystalloid solution if evidence of shock 

    • If suspecting bleeding, you may need to activate the Major Haemorrhage Protocol

  • Disability - GCS, pupillary response, blood sugar, temperature

  • Exposure - rashes, systemic signs of shock - expose the whole abdomen - there may be clues!!

 

During this acute phase state remember to provide constant reassessment

During initial assessment I would send bloods for FBC, U&E, LFTs, CRP, Lactate, blood glucose (lab test or Venous blood gas analysis and urine cultures if spiking a temperature. 

Focused history​

  • Allergies

  • Medications – VTE prophylaxis, analgesia, is the patient on antibiotics, diabetic medication, insulin dose, is the patient on a sliding scale

  • Past medical history – diabetes – type, usual treatment regimen of insulin or other antiyperglycaemics

  • Last meal, has patient been eating regularly

  • Events leading up to this point 

  • Indication for surgery: Any symptoms for precipitating hypoglycaemic event e.g. infection

Examination

This type of presentation warrants a thorough systemic review

  • Respiratory/chest/abdominal/neurological examination

    • In particular looking for a source of infection and potential complications secondary to DKA

Investigations

  • Blood tests– FBC, CRP, U&Es, LFTs, glucose, lactate, ketones, blood cultures if septic

  • ECG – look for arrhythmias related to potential electrolye disturbance e.g. hyperkalaemia/hypokalaemia

  • Septic screen – to assess for underlying precipitant of potential DKA

    • Chest X-ray

    • Urine dip – to look for possible signs of infection and evidence of ketones

    • Consider CT abdomen if concerns of collection

Initial management

  • Review Drug chart and diabetic medication 

  • Treat patient according to local Diabetic Ketoacidosis guidelines.

    • Likely to include

      • Placing patient on sliding scale

      • IV fluid replacement with potassium replacement

      • Urinary Catheter to monitor fluid input/output

  • Initiate antibiotics if concerns of infection based on local empirical guidelines

  • Regular monitoring of blood glucose/electrolytes/ketones

  • Discussion with urology registrar and medical registrar

Escalation

Consider discussion with:

  • ​General Surgical registrar

  • Medical registrar on call

  • Critical Care

Useful Resources

NICE- BNF: Management of diabetes in surgery

Joint British Diabetes Societies Inpatient Care Group - The Management of Diabetic Ketoacidosis in Adults 

Note: You may need an institutional or personal access to view some of these resources. Your medical education department or local NHS library may be able to help with access.

Example questions you may encounter during the station

Q1 - What are the principles of perioperative diabetes management?

 

  • Aim is maintain stable circulating glucose levels

  • Hypoglycaemia is more dangerouse that hyperglycaemia and therefore moderate hyperglycaemia is often acceptable. 

 

Q2 - What factors will influence perioperative glycaemic control?

  • Whether the diabetes is controlled by diet, medication or insulin

  • Magnitude of surgical stress

  • Presence of sepsis or other complications

  • Whether patient is nil by mouth

 

Q3 - How would you manage a diabetic patient prior to surgery?

core surgical training interview

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