PSUN251 Euglycemic DKA In A Patient Undergoing Major Surgery

BACKGROUND: Euglycemic DKA represents a diagnostic challenge as a lack of hyperglycemia can lead to a delay in recognition and administration of appropriate treatment. We present a case of euglycemic DKA in the setting of starvation and surgical stress in a patient with type 2 diabetes without SGLT2 inhibitor use. CLINICAL CASE: A 61-year-old type 2 diabetic woman presented with a two-day history of vomiting associated with abdominal pain. She was previously treated with glipizide, metformin, and sitagliptin, which had been discontinued months ago due to poor oral intake. CT imaging demonstrated a 12.4×11.2×10.5 cm pelvic mass with ascites and omental nodularity in the setting of a history of prior right granulosa cell tumor and mature cystic teratoma status post total abdominal hysterectomy with bilateral salpingo-oophorectomy. The patient subsequently developed hematemesis on hospital day 7, for which she was made NPO. She underwent EGD which demonstrated severe esophagitis and duodenitis. She was given an oral diet for one day, prior to resuming NPO status on hospital day 10 for exploratory laparotomy and tumor debulking. On hospital day 11, the patient's labs were notable for an anion gap metabolic acidosis (pH 7.26, n 7.4; CO2 16 mmol/L, n 20-31 mmol/L; anion gap 15 mmol/L, n 5-15 mmol/L), elevated beta-hydroxybutyrate (5.5 mmol/L, n 0.02-0.27 mmol/L), and a blood glucose range of 141-233 mg/dL (n 65-140 mg/dL). The patient was not on any scheduled insulin other than a low dose correctional scale with Lispro subcutaneously pre-meals and had not used SGLT2 inhibitors. There was no suspicion for alcohol toxicity or other poisoning given that the patient had been hospitalized. The lactate level was normal. Thus, the patient met criteria for euglycemic DKA likely secondary to prolonged fasting, exacerbated by the stress of major surgery. The patient was started on an insulin drip with dextrose infusion until the metabolic parameters improved, and she was transitioned to subcutaneous insulin. In diabetic patients unable to tolerate enteral nutrition or with enteral nutrition delays due to surgery, initiation of parenteral nutrition may prevent progression to euglycemic DKA. Ultimately, her pathology was consistent with metastatic granulosa cell tumor, and she was discharged to subacute rehabilitation. CONCLUSION: Euglycemic DKA may be overlooked due to normoglycemia leading to a delay in the diagnosis and appropriate management. It is a medical emergency and should be treated with an intravenous insulin infusion and dextrose. It can be prevented in diabetic patients undergoing major surgical stress by ensuring adequate nutritional support.Reference: Modi, A., Agrawal, A. and Morgan, F., 2017. Euglycemic diabetic ketoacidosis: a review. Current diabetes reviews, 13(3), pp.315-321. Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.