How to manage starvation ketoacidosis with lactic acidosis?

From the Guidelines

Management of starvation ketoacidosis with lactic acidosis requires prompt administration of intravenous dextrose along with insulin therapy and fluid resuscitation. The goal is to correct the metabolic disturbances, address the underlying cause of lactic acidosis, and improve the patient's morbidity, mortality, and quality of life. To achieve this, begin with 5% dextrose infusion at 100-125 mL/hour while simultaneously administering normal saline (0.9% NaCl) at 1-2 L over the first 2-4 hours to correct volume depletion, as seen in the management of diabetic ketoacidosis 1. Some key points to consider in the management include:

• Regular insulin may be required at 0.05-0.1 units/kg/hour if hyperglycemia develops during treatment.
• Electrolyte replacement, particularly potassium, phosphate, and magnesium, should be guided by serum levels.
• Thiamine (100 mg IV) should be administered before glucose to prevent Wernicke's encephalopathy.
• The underlying cause of lactic acidosis must be addressed, which may include treating infection, improving tissue perfusion, or discontinuing medications that impair lactate clearance.
• Bicarbonate therapy is generally avoided unless pH is below 7.1.
• Frequent monitoring of vital signs, electrolytes, glucose, and acid-base status every 2-4 hours is essential, similar to the monitoring approach for DKA or HHS 1. This approach works by providing carbohydrates to suppress ketogenesis while correcting fluid deficits and electrolyte imbalances. The insulin helps facilitate glucose uptake by cells and inhibits further ketone production, while addressing the underlying cause of lactic acidosis helps restore normal cellular metabolism.

From the FDA Drug Label

In metabolic acidosis associated with shock, therapy should be monitored by measuring blood gases, plasma osmolarity, arterial blood lactate, hemodynamics and cardiac rhythm. Bicarbonate therapy should always be planned in a stepwise fashion since the degree of response from a given dose is not precisely predictable Initially an infusion of 2 to 5 mEq/kg body weight over a period of 4 to 8 hours will produce a measurable improvement in the abnormal acid-base status of the blood.

To manage starvation ketoacidosis with lactic acidosis,

• Bicarbonate therapy should be planned in a stepwise fashion.
• The initial dose is 2 to 5 mEq/kg body weight over 4 to 8 hours.
• Monitoring should include blood gases, plasma osmolarity, arterial blood lactate, hemodynamics, and cardiac rhythm 2.
• The goal is to produce a measurable improvement in the abnormal acid-base status of the blood, not full correction in the first 24 hours.

From the Research

Management of Starvation Ketoacidosis with Lactic Acidosis

• The management of starvation ketoacidosis with lactic acidosis involves prompt recognition and early institution of appropriate therapy, including intravenous fluids, thiamine, and dietetic input 3, 4.
• It is essential to monitor fluid status and electrolytes closely, as starvation ketoacidosis can lead to severe electrolyte imbalance 3.
• In cases of starvation ketoacidosis with hypoglycemia, intravenous glucose and vitamin B1 administration may be necessary, followed by nutritional management 5.
• The use of dextrose-containing fluids has been shown to resolve acidosis and achieve favorable outcomes in pregnant patients with starvation ketoacidosis 6.
• Clinicians should be aware of the potential risks associated with a strict ketogenic diet, especially in breast-feeding mothers, and discuss these risks with patients who plan to breast-feed and lose weight following pregnancy 7.

Key Considerations

• Starvation ketoacidosis can present as a severe anion gap metabolic acidosis, and it is crucial to check ketones in patients with an unexplained metabolic acidosis 7.
• The condition can be easily missed, especially in patients who appear clinically well despite significant metabolic derangements 4.
• Early recognition and prompt intervention are vital to avoid life-threatening complications and achieve optimal maternal and fetal outcomes in pregnant patients 4, 6.