From the Guidelines
Treatment of starvation ketoacidosis complicated by rhabdomyolysis requires immediate and aggressive fluid resuscitation, electrolyte correction, and nutritional support to prevent life-threatening complications. The primary goal is to restore circulatory volume, correct electrolyte imbalances, and provide nutritional support to suppress ketogenesis and promote recovery.
- Begin with aggressive intravenous fluid administration using isotonic saline at 1-2 L in the first hour, followed by maintenance fluids based on the patient's hydration status, as suggested by the management of severe limb trauma patients 1.
- Administer dextrose-containing fluids (D5W or D10W) to provide carbohydrates and suppress ketogenesis, which is crucial in the treatment of diabetic ketoacidosis 1.
- Correct electrolyte imbalances, particularly potassium, phosphate, and magnesium, which are often depleted in both conditions, to prevent further complications.
- For rhabdomyolysis, maintain urine output at 200-300 mL/hour using IV fluids and consider mannitol or loop diuretics if needed to prevent acute kidney injury, as recommended in the guidelines for the acute care of severe limb trauma patients 1.
- Monitor creatine kinase levels, renal function, and electrolytes frequently to assess the effectiveness of treatment and prevent potential complications.
- Bicarbonate therapy may be necessary if severe acidosis persists (pH < 7.1) or if there's significant hyperkalemia, although its use is not recommended in diabetic ketoacidosis unless absolutely necessary 1.
- Initiate gradual nutritional rehabilitation with approximately 20-30 kcal/kg/day initially, increasing slowly to avoid refeeding syndrome, which is a critical aspect of treatment in starvation ketoacidosis. This combined approach addresses both the metabolic acidosis from starvation and the muscle breakdown, while preventing complications like acute kidney injury and electrolyte abnormalities that can be life-threatening in these interconnected conditions.
From the Research
Treatment for Starvation Ketoacidosis (SKA) Complicated by Rhabdomyolysis
- The treatment of rhabdomyolysis, a condition that can be complicated by SKA, remains controversial 2.
- Aggressive intravenous fluid resuscitation (IVFR) is conditionally recommended to improve outcomes of acute renal failure (ARF) and lessen the need for dialysis in patients with rhabdomyolysis 2.
- The use of bicarbonate or mannitol is not recommended for patients with rhabdomyolysis, as they do not improve the incidence of acute renal failure and need for dialysis 2, 3.
- Continuous renal replacement therapy (CRRT) may provide some benefits for people with rhabdomyolysis, such as removing potentially damaging myoglobin and stabilizing haemodynamic and metabolic status, but the evidence is limited and of poor quality 4.
- Early and aggressive fluid replacement using crystalloid solution is the cornerstone for preventing and treating AKI due to rhabdomyolysis 3, 5.
- Electrolyte imbalances must be treated with standard medical management, and the use of bicarbonates or diuretics may be helpful in some cases, but their indications should be well evaluated 3, 5.
- Renal replacement therapy, such as continuous venovenous hemodiafiltration, may be necessary in severe cases of rhabdomyolysis and acute renal failure, especially in patients with diabetic ketoacidosis 6.