Diabetic ketoacidosis with normal blood sugar, what the hell is this?

*It is only for medical professionals to read for reference.
Diabetic ketoacidosis may also be missed? ! Under what circumstances will it happen? Exploring the secrets in this issue will reveal the secrets for you! Diabetic ketoacidosis (DKA) is a common acute complication of diabetes.
It is not difficult to diagnose, including: blood sugar higher than 13.
9mmol/L, metabolic acidosis (arterial blood pH value <7.
3, serum HCO3- <18 mmol/L L), urine ketone or blood ketone is positive
.

But in some cases, DKA may also be missed! Do not believe? Consider this case: a male patient, 48 years old, was admitted to the orthopedics department with "lumbar disc herniation" due to "low back pain for 1 week"
.

He had a history of type 2 diabetes for 3 years, and he had taken acarbose 50mg tid, and his blood sugar control reached the standard
.

Have a history of fatty liver
.

Check 7.
0% glycosylated hemoglobin, liver and kidney function, and blood electrolytes are normal
.

The urine routine after admission showed urine ketone 2+ and urine sugar+
.

The patient had no special discomfort, and the blood sugar was 7.
6-9.
0mmol/L, which the doctor did not pay attention to
.

On the 3rd day of admission, the patient developed symptoms of fatigue, nausea and vomiting
.

Blood gas analysis showed PH 7.
28, actual HCO3-13.
9mmol/L, standard HCO3-12.
8mmol/L, blood electrolyte Na+133mmol/L, K+ 3.
4mmol/L, blood glucose 8.
0mmol/L, blood routine, blood and urine amylase , Blood lactate level and abdominal CT were normal
.

Asked about the medical history, the patient drank a lot of liquor in the past 2 days
.

Diabetic ketoacidosis (Euglycemic Diabetic Ketoacidosis, EDKA) with normal blood sugar is considered for diagnosis
.

Wait a minute-DKA with normal blood sugar, what the hell is this? ……What is EDKAEDKA is defined by blood glucose <11.
1mmol/L, metabolic acidosis, urine ketone or blood ketone positive
.

This shows that the difference between EDKA and DKA lies in the level of blood sugar
.

In 1973, Munro et al.
discovered 37 cases of EDKA among 211 cases of DKA for the first time
.

Whether it is type 1 diabetes or type 2 diabetes, EDKA may occur, and its incidence is not low
.

Some EDKA patients with blood glucose <7.
8mmol/L are also occasionally reported, but most of the so-called "normal blood glucose DKA" have blood glucose levels above the defined threshold
.

Therefore, the American Association of Clinical Endocrinologists believes that DKA with normal blood glucose is a misunderstood term, and it is recommended to use "DKA with lower than expected blood glucose level" instead
.

Who became the ketone body of EDKA? It is the general term for acetoacetic acid, β-hydroxybutyric acid and acetone in mammals
.

When the level of glucose metabolism decreases, the level of ketone bodies produced by the liver rises, and the ketone bodies are used as energy substrates for extrahepatic tissues
.

Why is the blood sugar normal or only slightly elevated during EDKA in diabetic patients? The underlying mechanism is: the output of glycogen in the fasting state is reduced; excessive counter-regulatory hormones (such as glucagon) increase urinary glucose excretion; the use of insulin reduces gluconeogenesis and increases extracellular glucose utilization
.

The final outcome is that after the blood sugar drops, fat mobilizes and breaks down to produce excess ketones for energy, consumes the body's alkali reserves, and finally causes metabolic acidosis
.

Like the causes of DKA, there are many causes of EDKA in diabetic patients, including hunger, low-calorie diet, excessive drinking, pregnancy, chronic liver disease, and decreased insulin dose
.

The use of sodium-glucose cotransporter 2 inhibitors (SGLT2i) is also one of the triggers, but it is very rare
.

The specific mechanism is shown in Figure 1
.

Therefore, excessive drinking is the inducement of EDKA in this patient
.

Figure 1 The possible pathogenesis of EDKA Why EDKA is easy to "fall through the net" The symptoms of EDKA patients can show dizziness, nausea and vomiting, dehydration, abdominal pain and other symptoms, but sometimes they are not as typical as DKA symptoms
.

Patients with EDKA have normal or mildly elevated blood sugar, which often masks the symptoms of DKA and easily leads to missed diagnosis
.

Therefore, for patients with unexplained nausea, vomiting, acidosis, and water loss, whether they have a history of diabetes or not, they should think about the possibility of this disease.
They should immediately check blood sugar, blood ketones, urine sugar, and urine ketones.
Blood ketones, urea nitrogen, creatinine, electrolytes, blood gas analysis, etc.
to confirm or rule out the disease
.

For patients similar to this case, the blood sugar is not high and the urine ketone is positive, you must think about the possibility of EDKA and actively explore the incentives
.

The differential diagnosis includes: DKA: DKA patients have more obvious symptoms of dehydration and acidosis, which are easy to distinguish from EDKA in blood sugar; Diabetic ketosis: During the development of EDKA, when the patient is in the compensatory stage of acid-base balance, it can only be manifested as Ketosis, no acidosis
.

 Other diseases: Acute pancreatitis, lactic acidosis can also cause symptoms such as vomiting, abdominal pain, and uremia coexisting with diabetes.
The above-mentioned laboratory tests can help identify them
.

Combination of prevention and treatment to save EDKAEDKA is also a life-threatening and critical illness, which should be diagnosed and treated as soon as possible
.

The treatment is the same as that of DKA, that is, rehydration, intravenous infusion of insulin, potassium supplementation, etc.
, to monitor changes in blood sugar and urine volume, and to remove the inducement of EDKA
.

In view of the inducement of EDKA, preventive work should be done in peacetime
.

For example, avoid excessive drinking or dieting, and pay attention to maintaining current carbohydrate intake
.

Patients using SGLT2i may trigger EDKA under stress conditions such as surgery and strenuous exercise.
Therefore, stop SGLT2i at least 24 hours before elective surgery or strenuous exercise (such as a marathon), emergency surgery or sudden severe external stress events Patients with diabetes should stop SGLT2i immediately to avoid the occurrence of EDKA
.

Summary EDKA is not uncommon.
It is a killer who is dormant around us.
It is easy to miss the diagnosis and we must be vigilant
.

Even if the blood sugar of diabetic patients is normal or slightly elevated, such as symptoms of metabolic acidosis, positive urine ketones, etc.
, they must actively investigate EDKA, treat them as soon as possible, and remove related incentives
.

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Euglycemic diabetic ketoacidosis: a diagnostic and therapeutic dilemma[J].
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AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTS AND AMERICAN COLLEGE OF ENDOCRINOLOGY POSITION STATEMENT ON THE ASSOCIATION OF SGLT-2 INHIBITORS AND DIABETIC KETOACIDOSIS.
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