Here’s an interesting case..
During a busy shift in A&E a 48-year-old lady presents with a two day history of epigastric pain, shortness of breath and signs of severe dehydration. Her heart’s going like a Ferrari and her blood pressure is super low. We take some bloods including a venous blood gas (VBG) and her pH is low, bicarb is low and glucose is 38 mmol/L. The brilliant resus nurse does her ketones which read as 3.5.
Can’t blame me for thinking this is diabetic ketoacidosis right? She’s a type II diabetic but it’s still possible.
So I start her on some fixed rate insulin. After an hour her glucose remains high and so does her ketones. We do a VBG and things remain the same. Maybe it’s a time thing? Who knows.
I’m now thinking - “where are her bloods?” I check to see the results and the urea and electrolytes (U&E) sample has haemolysed (fancy word for sample error).
Damn it - the patient is a bit chunky (no offence) so taking bloods is hard. So I try again and succeed. Her full blood count sample managed to process and her inflammatory markers are okay. Her chest X-ray looks clear with a normal urine dip. Not sure what the cause of this presentation is but she’s definitely pretty sick.
It’s all hard work. Her repeat VBG was.. interesting?!?. Her ketones are now normal but her glucose are high. Her pH has largely normalised. Perhaps she’s in a Hyperosmolar Hyperglycaemic State (HSS)? I switch her to a variable rate infusion to bring down her glucose slowly just incase she develops severe cerebral oedema.
Her U&E sample haemolysed again. I was pretty annoyed. I called the lab and asked what the reason was. The chap over the phone explained “it had excess lipids.”
“What does that even mean?” Is what I thought. The patient was crying out with abdominal pain. Her lactate was also really high but that could be dehydration related which is common in diabetic emergencies. It was time to call the medical registrar.
He came down, took a history and took another sample. The blood sample bottle looked like this:
He looked at me and said “she needs a surgical review.”
I was slightly bewildered as this patient has sugars through the roof, was clinically dehydrated and haemodynamically unstable. Turns out she had acute pancreatitis. So what happened?
Pancreatitis is life threatening. In some patients you have a huge surge in lipase as the pancreas attacks itself. This breaks down lipid compounds into free fatty acids which thickens the blood, giving the yellow layer which you see above. You also get digestion of islet cells which produce insulin. See some of the other causes of acute pancreatitis below:
This all happens over a period of time so the body becomes incredibly insulin resistant as inherently produced insulin reduces overtime. This is why these patients have high blood glucose that is severely resistant to treatment
So what did I learn?
High blood glucose in a patient with abdominal pain should always alert to possible pancreatitis.
Pancreatitis is a life threatening condition resulting in profound dehydration and severe pain.
Always think about why a sample has haemolysed. Was it because of a tight tourniquet? Did you leave the sample sitting for too long? Or is there another reason such as excess lipids?
This patient ended up going to intensive care. Before she left she had a CT scan confirming her diagnosis and had lots of fluids and pain relief. She was definitely looking better by the time she left A&E.
Hope that was beneficial.. So until next time!
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