Key Points
- Confirm diagnosis early with highest‑yield tests (and do not let testing delay time‑critical therapy).
- Use explicit hemodynamic, respiratory, and neurologic targets to guide escalation.
- Document disposition criteria, follow‑up, and patient education before discharge.
Algorithm
- Diagnose: AG metabolic acidosis with positive ketones and glucose <250 mg/dL.
- Stop SGLT2 inhibitor; identify triggers (infection, surgery, low carb intake).
- Start 0.9% saline; switch to D5/0.45% as glucose falls.
- Begin insulin infusion (e.g., 0.05–0.1 U/kg/h) with dextrose to continue ketone clearance.
- Replace potassium to target 4.0–5.0 mEq/L; hold insulin if K+ <3.3.
- Check gap, ketones, electrolytes every 2–4 h; adjust fluids/insulin.
- Transition to SC insulin when gap closes and oral intake resumes.
- Educate on sick‑day rules and perioperative SGLT2 cessation.
Clinical Synopsis & Reasoning
Anion‑gap ketoacidosis with glucose often <250 mg/dL in patients on SGLT2 inhibitors, during starvation, pregnancy, or perioperatively. Stop SGLT2 agent, initiate fluids, start insulin infusion with concurrent dextrose to clear ketones, correct electrolytes, and address triggers.
Treatment Strategy & Disposition
Stabilize ABCs. Initiate guideline‑concordant first‑line therapy with precise dosing and continuous monitoring. Escalate to advanced or procedural interventions when predefined failure criteria are met. Define ICU, step‑down, and ward disposition triggers explicitly, and arrange specialty consultation early.
Epidemiology / Risk Factors
- Risk varies by comorbidity and precipitating factors
Investigations
| Test | Role / Rationale | Typical Findings | Notes |
|---|---|---|---|
| CBC | Anemia/leukocytosis | Context‑specific | Trend response |
| BMP | Electrolytes/renal | Derangements common | Renal dosing/monitoring |
| Condition‑specific imaging | Per topic | Diagnostic hallmark | Do not delay with red flags |
| Serum/urine ketones (β‑hydroxybutyrate) | Diagnosis/severity | Elevated | Trend to closure |
| Anion gap/osmolality | Guide therapy | High gap, variable osmolality | Track every 2–4 h |
Pharmacology
| Medication | Mechanism | Onset | Role in Therapy | Limitations |
|---|---|---|---|---|
| 0.9% Saline → D5/0.45% | Crystalloid | Immediate | Resuscitation and ketone clearance | Adjust by osmolality/electrolytes |
| Regular insulin infusion | Insulin | Minutes | Clear ketones; close gap | Start dextrose early to avoid hypoglycemia |
| Potassium chloride | Electrolyte | Immediate | Maintain 4.0–5.0 mEq/L | Monitor frequently |
Prognosis / Complications
- Outcome depends on timeliness of diagnosis and definitive therapy
Patient Education / Counseling
- Explain red flags, adherence, and the follow‑up plan; provide written instructions.
References
- See bibliography — Link