Swaminathan Perinkulam Sathyanarayanan
The University of South Dakota Sanford School of Medicine
Sioux Falls, South Dakota
Disclosure information not submitted.
Khizar Hamid, MD
The University of South Dakota Sanford School of Medicine
Sioux Falls
Disclosure information not submitted.
Kari Taggart, PharmD
Pharmacist
Avera McKennan Hospital and University Health Center, South Dakota, United States
Disclosure information not submitted.
Kyle Gibbons, PharmD
Pharmacist
Avera McKennan Hospital and University Health Center, South Dakota, United States
Disclosure information not submitted.
Fady Jamous, MD
Associate professor of medicine
Avera McKennan Hospital and University Health Center, South Dakota, United States
Disclosure information not submitted.
Title: When the Machine Fails: A Different Approach to Euglycemic Diabetic Ketoacidosis Treatment.
Case Report Body:
Introduction: Euglycemic diabetic ketoacidosis (EDKA) is a clinical triad characterized by blood glucose < 200 mg/dL, anion gap metabolic acidosis and ketonemia. Conventional DKA management approaches with electronic glycemic management system (eGMS) are oftentimes unsuccessful in treating EDKA.
Description: A 44-year-old lady with history of type 2 diabetes mellitus on metformin and empagliflozin presented with abdominal pain, nausea and vomiting. Her vitals showed pulse 110/min, blood pressure 151/97 mmHg, respiratory rate 28/min and SpO2 100% on room air. She had diffuse abdominal tenderness on exam. Labs showed glucose 171 mg/dL, Na 133 mEq/L, K 4.1 mEq/L, Cl 104 mEq/L, CO2 4 mEq/L, creatinine 0.9 mg/dL, anion gap 25, beta-hydroxybutarate 63 mg/dL and normal lactate. Arterial blood gases showed pH 6.89, pCO2 11 mmHg, pO2 147 mmHg and HCO3 2 mEq/L. Computed tomography (CT) of the abdomen and chest X-ray were unremarkable. She was diagnosed with EDKA with combined gap and non-anion gap metabolic acidosis. She was transferred to the intensive care unit, made nil per oral, empagliflozin was held and fluid resuscitated with multiple normal saline (NS) boluses upto 10 L. Insulin drip per the hospital eGMS “Endotool” protocol, 5% dextrose - NS and bicarbonate drips were started. On day 2, she was on 1-2 U/hr insulin drip. Her anion gap was 10, CO2 9, Cl 114, Na 133 with glucose ranging from 120 to 180. Despite receiving upto 10 L intake, her net balance was only +4L because of high urine output. While her anion gap had closed, her CO2 remained low. Thus, she was switched from eGMS to insulin drip at a set rate of 3 U/hr with 10% dextrose drip. On day 3, labs showed CO2 18, Cl 115, Na 140, anion gap 7 and glucose running between 130 and 200. Insulin drip was stopped, subcutaneous insulin was started and she was transferred to the floor.
Discussion: Various eGMS’s have revolutionized the management of DKA in the United States. The insulin drip rates in eGMS are determined by the blood glucose and not the degree of acidosis. However, in EDKA with blood glucose levels < 200 mg/dL the insulin requirements are underestimated. These patients require higher percentage dextrose fluids (10 or 20%) to facilitate larger amounts of insulin administration to correct the severe acidosis while maintaining normal blood glucose levels.