Severe acidosis caused by starvation and stress

Perioperative urinary ketosis and metabolic acidosis in patients fasted for undergoing gynecologic surgery

BACKGROUND

Our bodies have adaptive mechanisms to fasting, in which glycogen stored in the liver and muscle protein are broken down, but also lipid mobilisation is triggered. As a result, glycerol and fatty acids are released into the bloodstream, increasing the production of ketone bodies in liver. However, there are limited studies on the incidence of perioperative urinary ketosis, the intraoperative blood glucose changes and metabolic acidosis after fasting for surgery in non-diabetic adult patients.

METHODS

We conducted a retrospective cohort study involving 1831 patients undergoing gynecologic surgery under general anesthesia from January to December 2022. Ketosis was assessed using a postoperative urine test, while blood glucose levels and acid-base status were collected from intraoperative arterial blood gas analyses.

RESULTS

Of 1535 patients who underwent postoperative urinalysis, 912 (59.4%) patients had ketonuria. Patients with ketonuria were younger, had lower body mass index, and had fewer comorbidities than those without ketonuria. After adjustments, younger age, higher body mass index and surgery starting late afternoon were significant risk factors for postoperative ketonuria. Of the 929 patients assessed with intraoperative arterial blood gas analyses, 29.0% showed metabolic acidosis. Multivariable logistic regression revealed that perioperative ketonuria and prolonged surgery significantly increased the risk for moderate-to-severe metabolic acidosis.

CONCLUSION

Perioperative urinary ketosis and intraoperative metabolic acidosis are common in patients undergoing gynecologic surgery, even with short-term preoperative fasting. The risks are notably higher in younger patients with lower body mass index. Optimization of preoperative fasting strategies including implementation of oral carbohydrate loading should be considered for reducing perioperative metabolic derangement due to ketosis.

Cellular response during cellular starvation: A battle for cellular survivability

Cellular starvation occurs when a cell is deprived of nutrition and oxygen availability. The genesis of this state of deprivation is exclusively contingent upon the inadequacy in the supply of essential components, namely amino acids, glucose, and oxygen. Consequently, the impact of this altered condition manifests in the regulation of cellular respiratory, metabolic, and stress responses. Subsequently, as a reactive outcome, cell death may transpire through mechanisms such as autophagy or apoptosis, particularly under prolonged circumstances. However, the cell combats such situations by evolving altered activity in their metabolic and protein level. Modulated signaling cascades help them to conquer starvation. But as in a prolonged condition, the battle that a cell has to evolve will come into and result in the form of cellular death. Therefore, in cancer therapy, cellular starvation may also act as a possible way out so that the cancer cell can undergo its death pathway in an induced starved condition. This review has collectively depicted the mechanism of cellular starvation. Besides this, the cellular response in this starved condition has also been summarized. Gaining such knowledge of the causation of cell starvation and cellular response during starvation not only generates new insight into the mechanism of cell survivability but also may act as a beneficial role in combating cellular diseases like cancer.

SGLT-2 inhibitor associated euglycaemic diabetic ketoacidosis in an orthopaedic trauma patient

Euglycaemic diabetic ketoacidosis is a serious but rare adverse effect of treatment with sodium-glucose cotransporter-2 (SGLT-2) inhibitors. A man in his 60s with type 2 diabetes mellitus underwent total hip replacement for an intracapsular neck of femur fracture. His SGLT-2 inhibitor was continued perioperatively and blood glucose levels were normal throughout the admission. A diagnosis of severe euglycaemic diabetic ketoacidosis was made in the operating theatre which required treatment in a critical care unit. This resulted in increased morbidity due to decreased postoperative mobilisation and a new requirement for subcutaneous insulin. This case highlights the need for withholding SGLT-2 inhibitors in patients admitted for emergency surgery and a need for regular ketone monitoring in these patients, even in the context of normoglycaemia.

Starvation ketoacidosis and refeeding syndrome

Starvation ketoacidosis (SKA) is a rarer cause of ketoacidosis. Most patients will only have a mild acidosis, but if exacerbated by stress can result in a severe acidosis. We describe a 66-year-old man admitted with reduced consciousness and found to have a severe metabolic acidosis with raised anion gap. His body mass index (BMI) was noted to be within the healthy range at 23 kg/m2; however, it was last documented 1 year previously at 28 kg/m2 with no clear timeframe of weight loss. While his acidosis improved with intravenous fluids, he subsequently developed severe electrolyte imbalance consistent with refeeding during his admission. Awareness of SKA as a cause for high anion gap metabolic acidosis is important and knowledge of management including intravenous fluids, thiamine, dietetic input and electrolyte replacement is vital.

Does the addition of dextrose to IV crystalloid therapy provide clinical benefit in acute dehydration? A systematic review and meta-analysis

Objectives

Intravenous dextrose aids in the resolution of ketosis in dehydrated patients not tolerating oral glucose and is often recommended in this clinical scenario. Our aim was to determine whether the addition of dextrose to intravenous rehydration solutions results in decreased hospital admissions or other clinically important benefits among dehydrated children or adults.

Methods

MEDLINE, EMBASE, Web of Science, SCOPUS, and the Cochrane Library were searched by a medical librarian from inception through November 2017. The inclusion criteria were randomized controlled trials comparing dextrose containing intravenous solutions with intravenous solutions without dextrose in patients being treated for dehydration, and not already hospitalized.

Results

The database and bibliographies search identified 1,472 unique citations. Only two trials (N = 333) met the inclusion criteria. Both compared normal saline with solutions of dextrose in normal saline. There was no statistically significant difference in admission rates (relative risk = 0.83; 95% confidence interval = 0.62 to 1.10) or revisits (relative risk = 0.54; 95% confidence interval = 0.24 to 1.22). Heterogeneity was low (I2 = 0). No other outcome results were eligible for pooling, but neither study found differences in any clinical outcomes. No adverse events were reported in either trial.

Conclusions

The addition of dextrose to intravenous saline has not been shown to improve clinical outcomes in dehydrated children presenting to the emergency department with gastroenteritis, but the confidence intervals around the estimate of effect are wide and include the possibility of substantial benefit.

Euglycemic Ketoacidosis in Spinal Muscular Atrophy

Euglycemic ketoacidosis is defined by the triad of high anion gap acidosis, increased plasma ketones, and the absence of hyperglycemia. Apart from diabetes mellitus, the disorder may occur in prolonged fasting, excessive alcohol consumption, pregnancy, and inborn errors of metabolism. Here, we highlight the diagnosis of euglycemic ketoacidosis in a pediatric nondiabetic patient with spinal muscular atrophy (SMA) type 1 (Werdnig–Hoffmann disease), who, subsequently to her postoperative admission to the intensive care unit following a spinal surgery, developed high anion gap metabolic acidosis. We discuss the pathophysiology of acid-base disorders in SMA, along with the glucose and fatty acids metabolism, the necessary knowledge for medical practitioners.

Combined metformin-associated lactic acidosis and euglycemic ketoacidosis

BACKGROUND

In renal failure metformin can lead to lactic acidosis. Additional inhibition of hepatic gluconeogenesis by accumulation of the drug may aggravate fasting-induced ketoacidosis. We report the occurrence of metformin-associated lactic acidosis (MALA) with concurrent euglycemic ketoacidosis (MALKA) in three patients with renal failure.

CASE PRESENTATIONS

Patient 1: a 78-year-old woman (pH = 6.89, lactic acid 22 mmol/l, serum ketoacids 7.4 mmol/l and blood glucose 63 mg/dl) on metformin and insulin treatment. Patient 2: a 79-year-old woman on metformin treatment (pH = 6.80, lactic acid 14.7 mmol/l, serum ketoacids 6.4 mmol/l and blood glucose 76 mg/dl). Patient 3: a 71-year-old man on metformin, canagliflozin and liraglutide treatment (pH = 7.21, lactic acid 5.9 mmol/l, serum ketoacids 16 mmol/l and blood glucose 150 mg/dl). In all patients, ketoacidosis receded on glucose infusion and renal replacement therapy.

CONCLUSION

This case series highlights the parallel occurrence of MALA and euglycemic ketoacidosis, the latter exceeding ketosis due to starvation, suggesting a metformin-triggered inhibition of gluconeogenesis. Affected patients benefit from glucose infusion counteracting suppressed hepatic gluconeogenesis.

Starvation Ketoacidosis as a Cause of Unexplained Metabolic Acidosis in the Perioperative Period

BACKGROUND Besides providing anesthesia for surgery, the anesthesiologist's role is to optimize the patient for surgery and for post-surgical recovery. This involves timely identification and treatment of medical comorbidities and abnormal laboratory values that could complicate the patient's perioperative course. There are several potential causes of anion and non-anion gap metabolic acidosis in surgical patients, most of which could profoundly affect a patient's surgical outcome. Thus, the presence of an acute acid-base disturbance requires a thorough workup, the results of which will influence the patient's anesthetic management. CASE REPORT An otherwise-healthy 24-year-old female presented for elective spine surgery and was found to have metabolic acidosis, hypotension, and polyuria intraoperatively. Common causes of acute metabolic acidosis were investigated and systematically ruled out, including lactic acidosis, diabetic ketoacidosis, drug-induced ketoacidosis, ingestion of toxic alcohols (e.g., methanol, ethylene glycol), uremia, and acute renal failure. Laboratory workup was remarkable only for elevated serum and urinary ketone levels, believed to be secondary to starvation ketoacidosis. Due to the patient's unexplained acid-base disturbance, she was kept intubated postoperatively to allow for further workup and management. CONCLUSIONS Starvation ketoacidosis is not widely recognized as a perioperative entity, and it is not well described in the medical literature. Lack of anesthesiologist awareness about this disorder may complicate the differential diagnosis for acute intraoperative metabolic acidosis and lead to a prolonged postoperative stay and an increase in hospital costs. The short- and long-term implications of perioperative ketoacidosis are not well defined and require further investigation.

Postmortem biochemistry in suspected starvation-induced ketoacidosis

Significantly increased blood ketone body levels can be occasionally observed in the forensic setting in situations other than exposure to cold, diabetic or alcoholic ketoacidosis. Though infrequent, these cases do occur and deserve thorough evaluation in order to establish appropriate differential diagnoses and quantify the role that hyperketonemia may play in the death process. Starvation ketoacidosis is a rare cause of metabolic acidosis and is a phenomenon that occurs normally during fasting, as the body switches from carbohydrate to lipid energy sources. The levels of ketonemia in starvation ketoacidosis is usually mild in comparison to those seen in diabetic or alcoholic ketoacidosis. In the clinical setting, several cases of starvation-induced ketoacidosis mainly associated with gastric banding, pregnancy, malnutrition and low-carbohydrate diets have been reported. However, starvation ketosis causing severe metabolic acidosis has been rarely described in the medical literature. In the realm of forensic pathology, starvation-induced hyperketonemia has been rarely described. In this paper we present the postmortem biochemical results observed in situations of suspected starvation-induced hyperketonemia that underwent medico-legal examination. In all these cases, the diagnosis of starvation induced-hyperketonemia and the subsequent ketoacidosis was established per exclusionem based on all postmortem investigation findings. A review of the literature pertaining to the clinical diagnosis of starvation ketoacidosis is also provided.

Metabolic acidosis mimicking diabetic ketoacidosis after use of calorie-free mineral water

A previously healthy boy was admitted with fever, tachycardia, dyspnea, and was vomiting. A blood test showed a severe metabolic acidosis with pH 7.08 and an anion gap of 36 mmol/L. His urine had an odor of acetone. The serum glucose was 5.6 mmol/L, and no glucosuria was found. Diabetic ketoacidosis could therefore be eliminated. Lactate level was normal. Tests for the most common metabolic diseases were negative. Because of herpes stomatitis, the boy had lost appetite and only been drinking Diet Coke and water the last days. Diet Coke or Coca-Cola Light is sweetened with a blend containing cyclamates, aspartame, and acesulfame potassium, all free of calories. The etiology of the metabolic acidosis appeared to be a catabolic situation exaggerated by fasting with no intake of calories. The elevated anion gap was due to a severe starvation ketoacidosis, mimicking a diabetic ketoacidosis. Pediatricians should recommend carbohydrate/calorie-containing fluids for rehydration of children with acute fever, diarrhea, or illness.

A severe case of iatrogenic lactation ketoacidosis

Lactation ketosis is a recognised disorder in postpartum lactating cows where a negative energy balance develops because the energy demands of milk production exceed the energy capacity of the animal. Rarely, nursing women can develop problems with lactation ketosis when their glycogen stores are depleted, causing the body to turn to gluconeogenesis as an energy substrate for galactopoiesis. The authors describe the case of a breastfeeding woman admitted to hospital and made nil per os (NPO) to treat a bowel obstruction. She did not receive intravenous glucose and 3 days postadmission developed a dangerous starvation ketosis (venous pH of 6.64). She was treated with intravenous dextrose, bicarbonate as well as cessation of breastfeeding and recovered quickly. Only four previous reports describe human lactation ketosis and this is the first iatrogenic case reported to our knowledge. It highlights the importance of addressing the unique caloric requirements of nursing women, especially when they are kept NPO.

Is salt, vitamin, or endocrinopathy causing this encephalopathy? A review of endocrine and metabolic causes of altered level of consciousness

Altered level of consciousness describes the reason for 3% of critical emergency department (ED) visits. Approximately 85% will be found to have a metabolic or systemic cause. Early laboratory studies such as a bedside glucose test, serum electrolytes, or a urine dipstick test often direct the ED provider toward endocrine or metabolic causes. This article examines common endocrine and metabolic causes of altered mentation in the ED via sections dedicated to endocrine-, electrolyte-, metabolic acidosis-, and metabolism-related causes.

A case of bovine ketoacidosis in a lactating woman

A 36 year-old 5 weeks postpartum lactating woman presented to the emergency room with severe nausea and vomiting for 48 hours. The patient was found to be in non-diabetic ketoacidosis with a serum pH 6.9 and a HCO₃ of <5mEq/L. This condition rapidly improved with the administration of intravenous dextrose and bicarbonate and with the cessation of breast feeding. The course and pathophysiology of the rarely described phenomenon of bovine ketosis in a human is discussed here.

A case of lactation "bovine" ketoacidosis

A 35-year-old postpartum lactating woman presented with dyspnea and was found to be in non-diabetic ketoacidosis (pH 7.24, HCO3 10 mmol/L, urine ketones>80 mg/dL). Rapid clinical and laboratory resolution occurred after intravenous dextrose and enteral feeding along with discontinuation of lactation. This represents a rarely reported case of lactation "bovine" ketoacidosis in humans. We review the historical precedence for the diagnosis and detail the underlying physiology.

Differential Diagnosis of Metabolic Acidosis

Metabolic acidosis is defined as an acidemia created by one of three mechanisms: increased production of acids, decreased excretion of acids, or loss of alkali. This article addresses the identification and correct diagnosis of metabolic acidosis by reviewing important historical factors, pathophysiological principles, clinical presentation,and laboratory findings accompanying common high and normal anion gap metabolic acidoses in emergency department patients.