Clinical Presentation

Step 1: Immediate Priorities

A. Rule Out Emergencies First

• Check for DKA / HHS: GRBS of 473 is critically high.
  • Check urine ketones (or blood ketones)
  • Check serum electrolytes, bicarbonate, anion gap, osmolality, BUN/creatinine
  • If ketones positive + acidosis → DKA protocol
  • If hyperosmolar, minimal ketones, altered sensorium → HHS protocol
• Check for CNS cause of giddiness: Hypertension + giddiness — rule out posterior circulation TIA/stroke (especially in a diabetic with vascular risk).
  • Assess HINTS exam / cerebellar signs / nystagmus / dysarthria
  • If any focal neuro signs → urgent neuroimaging (CT/MRI brain)
• BP 140/80: Not a hypertensive emergency, but above the recommended target for T2DM (<130/80 mmHg per AACE 2022 Guidelines, p. 5).

Step 2: Causes of Giddiness in This Patient

1. Osmotic/metabolic — severe hyperglycemia causes hyperosmolality → CNS symptoms including dizziness, lightheadedness
2. Postural hypotension — diabetic autonomic neuropathy; check lying/standing BP
3. Hypotension from dehydration — polyuria from glucosuria leads to volume depletion
4. Posterior circulation TIA/ischemia — diabetics are at high risk; BP elevation may reflect this
5. Hypertension-related — though 140/80 rarely causes giddiness alone, BP spikes can
6. BPPV or inner ear — coincidental, always possible
7. Hypoglycemia — less likely given GRBS 473, but rule out if on insulin and this is a rebound reading

Step 3: Investigations

Step 4: Management

Hyperglycemia (GRBS 473 mg/dL)

• If DKA: IV fluid resuscitation (0.9% NaCl), insulin infusion protocol, K+ replacement, close monitoring
• If HHS: Careful rehydration, insulin after adequate fluids
• If neither (simple uncontrolled T2DM):
  • Inpatient: Basal-bolus insulin regimen is preferred over sliding-scale insulin alone — proven superior in the RABBIT 2 trial (Perioperative Diabetes and Hyperglycaemia, p. 34)
  • Ensure adequate hydration (osmotic diuresis)
  • Hold metformin if volume-depleted or renal function impaired
  • Frequent GRBS monitoring (q2–4h)

Hypertension (BP 140/80)

• Target BP for T2DM: <130/80 mmHg
• This patient is above target — optimize antihypertensive therapy
• First-line: ACE inhibitor (e.g., ramipril) or ARB (e.g., telmisartan) — especially if any albuminuria/CKD
• Can combine with CCB or thiazide diuretic if needed
• Thiazide diuretics require caution given already high glucose
• Therapeutic lifestyle: low-sodium diet, weight management, physical activity

Giddiness (Symptomatic Management)

• Treat the underlying cause (hyperglycemia + dehydration most likely)
• Ensure patient is not orthostatic — if postural drop confirmed, review medications (diuretics, alpha-blockers), encourage adequate hydration, compression stockings
• If vestibular origin confirmed: vestibular rehabilitation, betahistine

Summary Disposition

Clinical note: A GRBS of 473 in a known T2DM patient with giddiness most commonly represents dehydration and osmotic symptoms from prolonged hyperglycemia, but DKA and CNS events must be actively excluded before attributing symptoms to hyperglycemia alone.

Rationale for NS in This Patient

NS Infusion Protocol

Initial Rate (General Guide for Uncontrolled T2DM / Possible HHS)

Adjust rate based on age, cardiac status, and renal function — go slower in elderly patients or those with heart failure/CKD.

Monitoring During IVF

• BP and HR every 30–60 min — watch for fluid overload or persistent hypotension
• GRBS every 1–2 hours — expect glucose to drop with fluids alone before insulin
• Urine output — target >0.5 mL/kg/hour
• Serum Na — in HHS, sodium may rise as glucose falls (corrected Na formula: add 1.6 mEq/L Na for every 100 mg/dL glucose above 100)
• Serum K+ — hypokalemia is common; do not start insulin until K+ ≥ 3.5 mEq/L

When to Switch from NS

Insulin Alongside IVF

• Once K+ confirmed ≥ 3.5 mEq/L:
  • If DKA: Regular insulin infusion 0.1 units/kg/hour IV
  • If HHS: Lower insulin dose 0.05 units/kg/hour IV (fluids are primary treatment)
  • If simple uncontrolled T2DM: Correction dose SC insulin (actrapid/regular) per sliding scale, then transition to basal-bolus