Euglycemia; a hideout for diabetic ketoacidosis

Abstract

An episode of diabetic ketoacidosis is normally initiated with hyperglycemia. However, hyperglycemia may not always be an indicator as ketoacidosis can occur with normal glycemic level as well. An elderly female with Chinese origin and history of type II diabetes, hypertension, dyslipidemia and ischemic heart disease was admitted to hospital with complaint of fever, urinary inconsistency and loose stool. Upon investigation, patient had higher values for capillary glucose, platelets and white blood count and lower values of sodium, potassium and red blood count. Treatment was initiated for gastroenteritis, urinary retention and anemia but patient developed metabolic acidosis which got severe after some time. Patient died later with death note of diabetic ketoacidosis secondary to sepsis. Euglycemic diabetic ketoacidosis is a well defined phenomenon. Patient in this case was however mildly hyperglycemic but was not given insulin. Alongside sepsis, increase in white blood count is also an attribute of dehydration and once diabetic ketoacidosis was ruled in, the rate of fluid resuscitation was not maintained as recommended by guidelines. Outcome of all these factors result in the death of patient. Hereby, we emphasize that guidelines for diagnosis of diabetic ketoacidosis should be applied upon every diabetic admission and followed during the management afterwards.

Full text

Atif Usman et al: Euglycemia; A hideout for Diabetic ketoacidosis
JPSI 1 (3), MAY – JUNE 2012, 44-45
Journal of Pharmaceutical and Scientific Innovation
www.jpsionline.com
Research Article
EUGLYCEMIA; A HIDEOUT FOR DIABETIC KETOACIDOSIS
Atif Usman*, Syed Azhar Syed Sulaiman, Amer Hayat Khan
Department of Clinical Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, Pulau Pinang, Malaysia
*Email: miyan.atif@gmail.com
Received on: 24/04/12 Revised on: 22/05/12 Accepted on: 10/06/12
ABSTRACT
An episode of diabetic k etoacidosis is normally initiated with hyperglycemia. However, hyperglycemia may not al ways be a n indicator as ketoacidosis can
occur with normal glycemic level as well. An elderly female with C hinese origin and history of type II diabetes, hypertension, dyslipidemia and ischemic heart
disease was admitted to hospital with complaint of fever, urinary inconsistency and loose stool. Upon investigation, patient had higher values for capillary
glucose, platelets a nd white blood count and lower values of sodium, potassium and red blood count. Treatment was initiated for gastroenteritis, u rinary
retention and a nemia but patient developed metabolic acidosis which got severe after some time. Patient died lat er with death note of diabetic ketoacidosis
secondary to sepsis. Euglycemic diabetic ketoacidosis is a well defined phenomenon. Patient in this case was however mildly hyperglycemic but was not given
insulin. Alongside sepsis, increase in white blood count is also an attribute of dehydration and once diabetic ketoacidosis was ruled in, the rate of fluid
resuscitation was not maintained as recommended by guidelines. Outcome of all these factors result in the death of patient. Hereby, we emphasize that
guidelines for diagnosis of diabetic ketoacidosis should be applied upon every diabetic admission and followed during the management a fterwards.
Keywords: Euglycemia, Diabetic Ketoacidosis, Laboratory Profiles, Diagnosis, Guidelines
INTRODUCTION
Acute complications of diabetes such as hypoglycemia or
hyperglycemia are life threatening and require more result
oriented medical decisions. DKA is usually triggered by
hyperglycemia which may be associated with infection, non-
compliance/adherence, or trauma of cardio and
cerebrovascular origin. Most guidelines for diagnosis of
DKA mention hyperglycemia above 13.9mmol/L1 though
ketosis and acidosis may be present with normal glycemic
level2. Acute complication disguised in another medically
attention seeking state, diverts the capacity of physician to a
different treatment. Thus, there should be diagnostic criteria
for DKA which should be applied on every diabetic patient in
order to get a clear picture. Hereby, we present a case in
which patient died attributable to euglycemic DKA secondary
to sepsis.
Case Report
A 70-year old Chinese female was admitted seeking medical
attention for fever, dysuria and loose stool, for 1 day. Patient
had history of type II diabetes, hypertension, dyslipidemia
and ischemic heart disease, and was being served with 1gm
metformin and 10mg glibenclamide, bd; 5mg amlodipine and
25mg hydrochlorothiazide, od with 25mg metoprolol bd;
40mg simvastatin oN; 10mg isosorbide dinitrate td and
150mg aspirin bd. Signs rendered patient being pale, mildly
dehydrated and lethargic. Temperature and blood glucose
level (BGL) were recorded to be 38.40c and 11.3mmol/dL
respectively.
Renal profile revealed hyponateremia (Na+ = 129mmol/L)
and hypokalemia (K+ = 3.1mmol/L) whereas complete blood
count gave an idea about sepsis (WBC = 13.5 ˣ 103/μL),
normocytic anemia (RBC = 2.78 ˣ 106/μL, Hb = 9.0g/dL,
MCV = 98.3fl) and hemorrhage (HCT = 25.9%) with a high
number of platelets (669 ˣ 103/μL). Hence impression was
made of urosepsis, gastroenteritis and hemorrhage. Treatment
was initiated with NS infusion at a rate of 60ml/h and
insertion of closed bag drainage (CBD) catheter. Potassium
was then added on from 2nd pint of NS. Cefemipe and
omeprazole were given to cover sepsis and gastroenteritis.
Tramadol and paracetamol were given to cover fever.
At 11th hour from admission, BGL of patient was reported to
be 22mmol/L. When attended, patient was found to have
SOB, tachypnoea and acidotic breath. Sample of blood was
sent for analysis of ketones and blood gasses. Ketones were
found to be 5.6mmol/L. DKA was ruled in and patient was
infused with 1 pint each of gelafundin and NS at fast rate.
Continuous insulin infusion was started at a rate of 8ii/h and
NS was then maintained at 85mL/h.
In the meantime, condition of patient deteriorated. PR and BP
went unrecordable at 12th hour. Dopamine, dobutamine and
later, noradrenaline were started to manage cardiogenic shock
which revived BP up to 162/92. At this time, result of venous
blood gas revealed that patient had developed metabolic
acidosis (pH = 7.13, Actual HCO3 = 8.1mmol/L) and hence
was given 8.4% NaHCO3. However, patient collapsed,
received a CPR and was revived after 10 minutes. Patient was
subsequently given IV adrenaline and calcium gluconate.
Results from 2n d blood sample for ABG (pH = 6.988, Actual
HCO3 = 7.5mmol/l) and CBC (WBC = 23.7 ˣ 103/μL)
revealed that patient had undergone severe metabolic
decompensation and dehydration. 2 pints of NS were given at
fast rate but patient re-collapsed at 13th hour from admission.
Second CPR was given for 20 minutes for which cardiac
monitor remained asystole and patient was pronounced dead.
DISCUSSION
Munro FJ et al. found that euglycemia in DKA may vary
from as low as 39mg/dL to as high as 299mg/dL2.
Furthermore they developed a notion that with increase of
BGL in DKA, Na+ and K+ decrease to as low as 128mmol/L
and 3.5mmol/L respectively2. The loss of electrolytes is
induced by hyperglycemia and ketosis when body tries to
compensate excess of glucose and ketone bodies via urine3.
BGL of patient in this case was lying near the upper threshold
of euglucemic DKA and patient also had hyponatremia and
hypokalemia at the time of admission which renders
condition of the patient more closely to an impending episode
of DKA. Apart from these initial findings, which left the
patient as a suspect for DKA, the sample was still not sent for
“urine full examination microscopy elements” (UFEME)
once the patient was inserted with CBD catheter. Ketones
would have been detected immediately at that time which

Atif Usman et al: Euglycemia; A hideout for Diabetic ketoacidosis
JPSI 1 (3), MAY – JUNE 2012, 44-45
actually had resulted in a lot more different treatment
protocol. Bacon DK et al. concluded that leukocytosis may be
observed along with increase in temperature as a result of
acute dehydration4. In this case, patient’s number of WBC
was high at the time of admission and so was the
temperature. However, this increase of WBC was translated
as sepsis knowing well that dehydration, which is a definite
attribute of DKA, might be the reason of leukocytosis as
patient was also found to be dehydrated during initial
assessment at the time of admission. There are number of
studies which concluded that abdominal pain does have a
relation with DKA2, 3, 5, 6. This relation though is unexplained
but severity of pain is observed more likely in patients with a
severe metabolic acidosis5. Patient, hereby discussed, also
complained for having abdominal pain. All of these initial
findings point toward euglycemic DKA.
For the part of management, recommended guidelines
suggest that intravenous fluid resuscitation should be initiated
at 2000mL/h and 1400mL/h for management of DKA and
hyperglycemia and then maintained at a rate of 200mL/h and
140mL/h respectively1. Considering that the patient was
hyperglycemic, fluid replacement even then was not in
accordance with the guidelines to manage hyperglycemia1, 7.
Moreover, once DKA was ruled in, the infusion rate was still
half to the rate recommended by guidelines to manage DKA.
Furthermore, it is recommended that patient should be started
on constant insulin infusion and managed afterwards with
help of 5% or 10% dextrose3, 7. Yet, insulin was not injected
nor was BGL checked for 11 hours.
Except for the fluid reconstitution and insulin, the rest of the
protocol followed was according to guidelines. Patient was
given NaHCO3 and potassium replacement for management
of severe acidosis and hypokalemia1, 3, 7. The use of NaHCO3
remains controversial but it is still recommended if patient
undergoes severe metabolic acidosis. Patient was also given
gelafundin to overcome hypovolemia8. Use of dopamine,
dobutamine and adrenaline is also in accordance with
recommendations to overcome cardiogenic shock9, 10.
CONCLUSION
Euglycemic DKA was first reported in 1973 and with help of
aforementioned case, it is highlighted that more attention
should be paid to its attributes. By following this example,
one can prevent a minor error which may even end in death.
Symptoms and signs are very important during initial
assessment for a diabetic patient as a minute slip-up may lead
patient’s struggling homeostatic physiochemical state to face
a completely different treatment protocol. All initial
biochemical and laboratory tests should be carried out to rule
in DKA such as for ketones and pH/HCO3 of blood. We also
emphasize that there should be a critical guideline for each
patient getting admission to hospital, which may help ruling
out diabetic ketoacidosis from similar acute diabetic
complications.
This research is registered with “National Medical
Research Register (NMRR) Malaysia” and approved by the
“Clinical Research Committee (CRC) Malaysia.
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