63 year-old Man with Hypoglycemia. Sharon H. Chou, MD Endorama January 5, 2012
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1 63 year-old Man with Hypoglycemia Sharon H. Chou, MD Endorama January 5, 2012
2 History of Present Illness 63-year-old man with past medical history significant for systolic CHF (EF 25%), critical aortic stenosis (valvular area of 0.8 cm 2 ), CAD, and ESRD on HD who was discharged earlier in the day after hospitalization for decompensated heart failure. Hospitalization: 9/23/11-10/2/11 Aortic valvuloplasty Complicated by watershed infarction noted on MRI After leaving the hospital, he went to McDonald s, had a hamburger, and acutely developed shortness of breath and chest pain. Underwent bioprosthetic AVR and CABG. Complicated by sepsis, presumed to be secondary to line infection. Noted to be persistently hypoglycemic POD #1
3 Glucose Trend Hospitalization: 9/23/11-10/2/11 Serum glucose: Accuchecks: Current Hospitalization: 10/2/11-10/11/11 Serum glucose: Accuchecks: Aortic valve replacement and CABG: 10/11/11 POD #1: Serum glucose: 53 Accuchecks: 64, 55, 52, 84
4 Glucose Trend cont. Accuchecks 64, 55, 52, s s Endocrine consulted POD 0 10/11 D10 NS at 42 cc/hr POD 15 10/24 Osmolite 1Kcal at 60 cc/hr Dobhoff clogged Held for HD catheter replacement
5 Past Medical History Past Medical History Systolic congestive heart failure, EF 25% Severe aortic stenosis Coronary artery disease h/o stroke in 2001 with expressive asphasia ESRD on HD for past 3 years Hypertension Hyperlipiemia Allergies: NKDA Medications: Ampicillin 1 gram q12 hr ASA 81 mg daily Carvediol 6.25 mg BID Lisinopril 5 mg daily Simvastatin 40 mg daily Thiamine 100 mg daily Folic acid 1 mg daily Ipratropium nebulizer 6 hrs Mucomyst nebulizer q6 hrs Sennosides-Docusate Heparin SQ
6 Past Medical History cont. Social History: Lives with his wife, has 4 grown children Previously worked in a funeral home. Denies history of tobacco use. Prior heavy ETOH user until 2001: ½ pint per day from Denies history of illicit drugs Family History: Sister with DM2. No family history of cancer. ROS: Unable to obtain due to delirium. Unintentional weight loss: 187 lbs to 132 lbs over 2 years. Per wife, appetite was good at home and the other hospital.
7 Physical Exam T 95.7, BP 107/70, Pulse 91, Resp 35, SpO2 100% on trach collar Ht cm (5' 10"), Wt 59.9 kg (132 lb 0.9 oz), BMI kg/m 2 Constitutional: Patient appears chronically ill. Follows commands. Does not answer questions. Mildly lethargic. HEENT: Conjunctivae are not injected. Sclerae anicteric. Pupils are equal, round, and reactive to light. Neck: Trach collar in place. Cardiovascular: Regular rhythm and rate. Diminished distal pulses. Pulmonary/Chest: Normal respiratory effort. Diffuse rhonchi. Incision c/d/i. Abdomen: Normoactive bowel sounds. Soft, nontender, nondistended. Musculoskeletal: LUE edematous. Neurological: Weak grip strength bilaterally. Skin: Skin is warm and dry. Psychiatric: Difficult to assess mood and affect.
8 Laboratory Data Ca 8.2, alb %N, 7%L, 6% M, 2%E TB 1.1, DB 0.6, alk phos 57, AST 81, ALT 9 INR 1.3 Prealbumin 3 mg/dl (21-41) 9/28: HgbA1c 5.1% 10/13 12PM Cortisol /17: 2AM Cortisol /23: TSH 3.37
9 Causes of Hypoglycemia J Clin Endocrinol Metab Mar;94(3):
10 Common causes of hypoglycemia in hospitalized, non-diabetic patients Retrospective review: 88 patients with BS <50. Causes found in 72% of patients, 24% with more than one. Common causes: Chronic renal failure, 25% Alcohol intoxication, 15% Liver failure, 12% Sepsis, 12% Cancer, 12% Endocrine disorders, 12% 16% died. Endocr Pract Mar-Apr;11(2):91-6.
11 Assessment & Plan Assessment: Contributing factors: ESRD Cardiac failure Malnutrition: pre-albumin 3? liver disease: history of ETOH use, slightly elevated INR Sepsis: line infection Rule out: insulinoma, adrenal insufficiency, malignancy Plan: Halve the rate of dextrose infusion for 2 hours then stop. Once blood sugar is <50, please draw C-peptide, insulin, pro-insulin, beta hydroxybutyrate, and cortisol levels.
12 Critical Sample :00 14:00 15:00 16:00 17:00 Insulin <2.0 uiu/ml (<28.5) C-peptide 0.81 pmol/ml ( ) Proinsulin 9.5 pmol/l (3-20) ß-hydroxybutyrate 0.11 mmol/l (<0.30) Cortisol 13.5 mcg/dl
13 Work-up of Hypoglycemia Accucheck 52 mg/dl Insulin <2.0 uiu/ml (<28.5) C-peptide 0.81 pmol/ml ( ) Proinsulin 9.5 pmol/l (3-20) ß-hydroxybutyrate 0.11 mmol/l (<0.30) Cortisol 13.5 mcg/dl J Clin Endocrinol Metab Mar;94(3):
14 More tests IGF-1: 77 ng/ml (75-212) IGF-II: 546 ng/ml ( ) CT chest: Thrombus at brachiocephalic confluence.
15 Follow up Difficult course include PEA arrest. Weaned off D20 gtt on 11/8. Had no further hypoglycemic episodes. Started on stress dose steroids for?adrenal insufficiency. Cort stim: 19.3 (ACTH 215) Discharged to rehab on 11/15.
16 Risk Factors in our Patient ESRD: 1545 admissions of ESRD patients 3.6% admitted with hypoglycemia, 32% were non-diabetic Causes: Mechanisms: Decreased degradation of insulin, sulfonylureas Decreased renal gluconeogenesis Hyperkalemia associated with hyperinsulinemia and hypoglycemia Malnutrition in ESRD Autonomic neuropathy with diminished counter-regulatory hormonal reaction to hypoglycemia Ren Fail Mar;22(2):
17 Risk Factors in our Patient Starvation Depleted hepatic glycogen reserves and gluconeogenic substrates. Supported by sensitivity to short-term fasts. Depleted fat stores. Supported by undetectable serum ketones. Can lead to low insulin levels that are insensitive to glucose infusion. Delayed insulin response to feeding with postprandial hypoglycemia. Protected by continuous feeds. Arch Intern Med Apr;150(4): Curr Opin Pediatr Aug;23(4):390-4.
18 References Arch Intern Med Apr;150(4): Best Pract Res Clin Endocrinol Metab Jun;19(2): Curr Opin Pediatr Aug;23(4): Dig Surg. 2011;28(1): Endocr Pract Mar-Apr;11(2):91-6. Eur Radiol Oct;19(10): J Clin Endocrinol Metab Mar;94(3): Medicine (Baltimore) May;88(3): Ren Fail Mar;22(2): World J Surg Sep;33(9):
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