What is the best management approach for a patient with hyperglycemia, dyspnea, vomiting, polyuria, polydipsia, an infected wound, unexplained weight loss, and blurred vision, currently on Gliclazide?

Immediate Hospitalization and Evaluation for Diabetic Ketoacidosis

This 28-year-old female presenting with hyperglycemia, vomiting, dyspnea, polyuria, polydipsia, unexplained weight loss, blurred vision, and an infected wound requires immediate hospitalization for suspected diabetic ketoacidosis (DKA) with severe diabetic foot infection. 1

Initial Assessment and Stabilization

Confirm DKA Diagnosis

• Obtain immediate laboratory tests: arterial blood gas (pH), serum bicarbonate, serum or blood ketones (β-hydroxybutyrate preferred), complete metabolic panel, anion gap calculation, and urinalysis 1, 2, 3
• DKA diagnostic criteria: blood glucose >250 mg/dL, arterial pH <7.3, bicarbonate <15 mEq/L, and moderate ketonemia or ketonuria 2, 3
• The combination of vomiting with suspected ketosis strongly indicates DKA requiring immediate medical attention 2
• Polyuria, polydipsia, weight loss, and dehydration are classic presenting features of hyperglycemic crises 1, 3

Assess Infection Severity

• This patient has a severe diabetic foot infection based on systemic toxicity (vomiting) and metabolic instability (severe hyperglycemia) 1
• Patients with severe infections or metabolic instability should be hospitalized 1
• The infected wound is likely a precipitating factor for DKA 1, 2

Immediate Management Protocol

Fluid Resuscitation (First Priority)

• Begin with isotonic saline (0.9% NaCl) at 15-20 mL/kg/hr in the first hour to restore circulatory volume 2
• After the first hour, continue at 4-14 mL/kg/hr based on hemodynamic status 2
• Restoration of fluid and electrolyte balance is essential before other interventions 1

Insulin Therapy (Second Priority)

• Discontinue gliclazide immediately - sulfonylureas should be avoided during acute illness and when starting insulin therapy 4, 5
• Gliclazide can cause loss of blood glucose control during stress, infection, or surgery, necessitating insulin 5
• Start continuous IV regular insulin at 0.1 units/kg/hr after fluid resuscitation has begun 2
• If glucose does not fall by 50-75 mg/dL in the first hour, double the insulin infusion rate 2
• Once blood glucose reaches 200-250 mg/dL, add dextrose to IV fluids while continuing insulin to prevent hypoglycemia 2

Electrolyte Management (Concurrent Priority)

• Monitor serum potassium every 2-4 hours as insulin therapy causes hypokalemia 2
• Begin potassium replacement when levels fall below 5.2 mEq/L (with adequate urine output), typically 20-30 mEq per liter of IV fluid 2
• Monitor electrolytes, BUN, creatinine, and venous pH every 2-4 hours 2

Infection Management

• Obtain wound cultures before starting antibiotics 1
• Initiate broad-spectrum parenteral antibiotics immediately covering gram-positive cocci (including MRSA if prevalent locally), gram-negative organisms, and obligate anaerobes 1
• Correction of hyperglycemia aids in eradicating infection and wound healing 1
• Hyperglycemia impairs polymorphonuclear leukocyte mobilization, chemotaxis, and phagocytic activity 6

Ongoing Monitoring

Metabolic Monitoring

• Check blood glucose every 1-2 hours until stable 2
• Monitor for signs of cerebral edema: headache, altered mental status, seizures, bradycardia 2
• Continue monitoring until DKA resolves (pH >7.3, bicarbonate >15 mEq/L, anion gap normalized) 2

Target Glucose Range

• Maintain blood glucose 140-180 mg/dL during acute illness to avoid both hyperglycemia complications and hypoglycemia risk 4, 7
• Blood glucose >200 mg/dL has been associated with neurological worsening and should be treated 7

Transition and Discharge Planning

Transition to Subcutaneous Insulin

• Once DKA resolves, transition to subcutaneous insulin regimen 2
• Administer subcutaneous basal insulin 2-4 hours before discontinuing IV insulin to prevent recurrence 2
• Calculate total daily insulin dose at 0.5-0.8 units/kg/day, divided into 50% basal and 50% prandial insulin 4

Address Underlying Diabetes Management

• This patient likely has type 1 diabetes given young age, DKA presentation, unexplained weight loss, and failure on oral agent alone 1
• Basal insulin should never be stopped in insulin-dependent patients due to ketoacidosis risk 4, 7
• Consider screening for eating disorders given unexplained weight loss and hyperglycemia 1

Patient Education (Critical for Prevention)

• Provide sick-day management education: never stop insulin during illness, monitor blood glucose and ketones when glucose >200 mg/dL, maintain hydration, seek immediate care for vomiting or persistent hyperglycemia 1, 2
• Educate on DKA warning signs: polyuria, polydipsia, nausea, vomiting, abdominal pain, dyspnea 2, 3
• Ensure uninterrupted access to insulin and diabetes supplies 3

Common Pitfalls to Avoid

• Never continue sulfonylureas during acute illness or DKA - they are ineffective and increase hypoglycemia risk 4, 5
• Do not use sliding-scale insulin as monotherapy - this approach is ineffective and causes wide glucose fluctuations 4
• Never discontinue insulin completely in insulin-dependent patients, even when infection resolves 4
• Do not delay hospitalization - patients with systemic toxicity and metabolic instability require inpatient management 1
• Avoid targeting overly strict glycemic control (<140 mg/dL) during acute illness as this increases hypoglycemia risk 4