Refractory hypovolemic shock in a 20-year-old man with hyperosmolar hyperglycemic state

Introduction: Hyperosmolar hyperglycemic state (HHS) is characterized by highly elevated serum glucose levels and hyperosmolality without significant ketosis. It commonly affects adults with type 2 diabetes (T2DM). Studies have reported increasing incidence of HHS in patients with type 1 diabetes (T1DM). Insulin deficient states such as HHS and DKA can result in hypertriglyceridemia (HTG), which can cause acute pancreatitis. The combination of HHS, HTG, acute pancreatitis has not been well described. Description: A 20-year-old male with poorly controlled T1DM was admitted with severe hypovolemic shock from HHS. He presented unresponsive and hypotensive with an initial pH of 6.7 and glucose >1400 mg/dL and was intubated. Multiple fluid boluses and an insulin drip were administered, and he was started on multiple vasopressors due to fluid refractory shock. Pertinent labs included BUN and creatinine 49 and 2.7 mg/dL, plasma osmolarity 343 mOsm/kg, lipase 1197 U/L and triglycerides 1065 mg/dL. Insulin drip was titrated with close monitoring of blood glucoses and blood gases. His HHS resolved on day 3 of hospitalization. With slow correction of his HHS and subsequent HTG, his lipase improved and normalized on day 4. Until then he continued to be hemodynamically labile requiring high rates of multiple vasopressors despite aggressive intravenous hydration. Due to worsening renal function and dyselectrolytemia, continuous renal replacement therapy (CRRT) was initiated. He was extubated on day 14 and trialed off CRRT with improving kidney function on day 17. Discussion: Insulin deficient states can activate lipolysis and release of free fatty acids. The subsequent HTG increases the risk of acute pancreatitis when serum triglyceride levels are >500 mg/dL. Few case reports describe the triad of HHS, HTG and acute pancreatitis. Acute pancreatitis is often overlooked in the setting of severe metabolic and neurological derangements in HHS. Even though, acute pancreatitis was recognized early in our patient, along with HHS, it likely contributed to his unusually long course of hypovolemic shock and acute kidney injury. Delayed diagnosis of acute pancreatitis and its complications in the setting of HHS can be life threatening and requires a high index of suspicion.