Poster Presentation ESA-SRB-APEG-NZSE 2022

FW, a 23-year-old female with Type 1 Diabetes Mellitus managed with Dexcom 6 basal IQ technology, was admitted for management post a severe prolonged hypoglycaemic episode associated with status epilepticus. FW had well controlled (HbA1c 7.0%), uncomplicated diabetes with infrequent hypoglycaemic episodes. The presenting hypoglycaemic episode occurred in the context of exercise, alcohol and possible gamma hydroxybutryic acid spiking.

Review of device data revealed prolonged hypoglycaemia (glucose <2mmol/L) for ten hours (Figure 1 and 2). Predictive low glucose suspend activated with resumption of basal insulin every two hours, in alignment with pump safety measures, before again suspending. Despite limited basal insulin overnight, FW remained hypoglycaemic, indicating alpha cell dysfunction or poor glycogen reserve. Ketones were 0.2mmol/L when first recorded hours after her initial management in a rural clinic.

Electroencephalogram recorded status epilepticus, MRI-Brain was consistent with hypoglycaemic encephalopathy with FLAIR hyperintensity and restricted diffusion of the basal ganglia and hippocampi tails with mild cerebral oedema. Interval imaging noted new signal hyperintensity and diffusion restriction in the anterior globus pallidus bilaterally with likely resolving mild cerebral oedema. FW had multiple failed attempts at extubation before decision for tracheostomy. Over the subsequent weeks there was slow and poor neurological recovery resulting in eventual withdrawal of care and death. Whilst organ donation was considered, she was deemed an unsuitable donor as time to death post withdrawal of care exceeded ninety minutes. 

This case allows the unique perspective to scrutinize continuous glucose monitoring during prolonged severe hypoglycaemia and assess safety features of insulin pump. Safety of insulin pumps in the areas of software, hardware, wireless communication, human factors, alarms and bolus calculators will be discussed. As will the ethics regarding onus on practitioners who are set up as safety alert contacts. This case highlights the benefits of dual-hormone artificial pancreas system