(286) Severe Hyperglycemia in a Burn Patient

Introduction: Patients with severe burns covering more than 40% total body surface area (TBSA) experience stress, inflammation, and hypermetabolism. Although seen in other critically ill patients, the severity and duration of the hypermetabolic and hyperglycemic stress response is especially pronounced in burn patients.
In this case report, we present a patient who sustained 45% TBSA full thickness burns with extreme insulin resistance and hyperglycemic response. His course illustrates the unique hypermetabolic state present in burn patients and emphasizes the ability to safely administer insulin even in enormous doses.

Description: A 35-year-old male presented with 45% TBSA mixed thickness burns to face, bilateral upper and lower extremities, chest, and abdomen. His admission hemoglobin A1c was 6.7% without previous diagnosis of diabetes, and he was started on metformin for management of his Type 2 diabetes and insulin resistance associated with his severe burn injury. Following excision of his burn wounds on post burn day (PBD) 4, an insulin infusion was initiated for hyperglycemia with a goal blood glucose of 180 mg/dL. Over the next two weeks, his hypermetabolic state worsened substantially with him requiring ECMO cannulation for severe acute lung injury on PBD 11. Insulin requirements continued to rise from 882 units/ 24 hours to a maximum of 5739 units/ 24 hours on PBD 15. Despite these massive insulin doses, he remained hyperglycemic with a maximum blood glucose of 227 mg/dL. By PBD 19, the patient’s insulin requirement decreased to 475 units for a 24-hour period, the first time in seven days that the insulin requirement was less than 1000 units. No episodes of hypoglycemia occurred during this period.

Discussion: To attempt to achieve a blood glucose level of less than 180 mg/dl, the insulin requirements seen in this patient were unlike any requirements recorded since 1943 with exceptionally high doses of insulin for two weeks during his hospitalization. This case report not only underscores the uniquely severe hypermetabolic state present in burn patients, but also emphasizes the safety of insulin even in massive doses when required by the patient.