How to manage a surgical patient with hyperglycemia and ketosis, with a blood sugar level of 11 mmol/L and ketones of 2.2 mmol/L, who is fasting for theatre?

Management of Surgical Patient with Hyperglycemia and Ketosis

For a surgical patient with blood sugar level of 11 mmol/L and ketones of 2.2 mmol/L who is fasting for theatre, transfer to ICU for IV insulin infusion therapy is required due to significant ketosis. 1

Assessment and Initial Management

The patient presents with moderate hyperglycemia (11 mmol/L) but significant ketosis (2.2 mmol/L), which meets criteria for diabetic ketoacidosis requiring immediate intervention. According to the perioperative management guidelines, ketone levels ≥1.5 mmol/L warrant transfer to ICU for intravenous insulin therapy, regardless of the blood glucose level 1.

Step-by-Step Management:

1. Immediate Actions:

   • Transfer the patient to ICU for IV insulin infusion therapy
   • Postpone surgery except in life-threatening emergencies
   • Initiate IV fluid resuscitation with 0.9% saline

2. Insulin Therapy:

   • Start intravenous insulin infusion via electronic syringe pump
   • Monitor blood glucose and ketones hourly until ketosis resolves
   • Continue insulin therapy until anion gap normalizes and metabolic acidosis reverses

3. Fluid and Electrolyte Management:

   • Ensure adequate hydration with IV fluids
   • Monitor and replace electrolytes, particularly potassium
   • Add dextrose to IV fluids once blood glucose falls below 14 mmol/L to prevent hypoglycemia while continuing insulin

Special Considerations

Possible Euglycemic DKA

This presentation may represent euglycemic diabetic ketoacidosis (EDKA), which is characterized by metabolic acidosis, ketonemia, and relatively normal blood glucose levels (<14 mmol/L) 2. This condition is particularly challenging to diagnose due to the absence of significant hyperglycemia, which can delay recognition 3.

Risk Factors to Assess

• Check if patient is on SGLT2 inhibitors, which increase risk of euglycemic DKA 4
• Assess for insulin pump failure if the patient uses one 2
• Consider if prolonged fasting, infection, or surgical stress has contributed to ketosis 1

Post-Acute Management

Once ketosis resolves and the patient stabilizes:

1. Transition from IV to SC insulin:

   • Calculate subcutaneous insulin doses based on IV requirements:
     • Total slow-acting insulin = ½ of total IV insulin/24h
     • Rapid-acting insulin per meal = ½ of total IV insulin/24h divided by 3 1
   • Reduce doses by 50% if insufficient caloric intake

2. Ongoing Monitoring:

   • Continue frequent blood glucose monitoring
   • Check ketones if blood glucose exceeds 11 mmol/L
   • Assess HbA1c to guide long-term management

Pitfalls and Caveats

1. Do not delay treatment based on "normal" blood glucose levels - ketosis of 2.2 mmol/L requires immediate intervention regardless of glycemic status 1

2. Avoid rapid correction of electrolyte abnormalities, particularly potassium, which can lead to cardiac arrhythmias

3. Do not stop insulin before ketosis has fully resolved, even if blood glucose normalizes

4. Recognize that surgical stress can worsen hyperglycemia and ketosis, making perioperative management particularly challenging

5. Consider postponing elective surgery until metabolic derangements are corrected to reduce perioperative complications

The presence of significant ketosis (2.2 mmol/L) with hyperglycemia in a fasting surgical patient represents a serious metabolic derangement that requires prompt and aggressive management with IV insulin therapy in an ICU setting to prevent progression to severe ketoacidosis and associated complications.