SHM Converge Scientific Abstract ePoster Gallery-Post-Operative Euglycemic Ketoacidosis in a Patient With Prediabetes and No Prior Sglt2 Inhibitor Use

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This case describes a 71-year-old man with prediabetes, hypertension, and paraplegia who developed postoperative euglycemic ketoacidosis after right shoulder arthroplasty, despite no prior SGLT2 inhibitor use. On postoperative day 2, he had persistent sinus tachycardia and frequent PVCs despite fluid resuscitation. He was thin, appeared mildly volume depleted, and had no evidence of infection, pulmonary embolism, or other obvious postoperative complication.<br /><br />Key diagnostic findings included a mild high anion gap metabolic acidosis (anion gap 16, pH 7.32, low pCO2 29), elevated beta-hydroxybutyrate (3.95 mmol/L), glucosuria and ketonuria, and only mild blood glucose elevations (112–176 mg/dL). Lactate was normal, and cultures and imaging were negative. These findings supported euglycemic ketoacidosis rather than classic diabetic ketoacidosis.<br /><br />The discussion emphasizes that euglycemic ketoacidosis can occur in at-risk patients even without diabetes medications, particularly after acute stressors such as surgery, fasting, or in the setting of poor nutritional reserve. In this patient, contributing factors likely included postoperative carbohydrate deficit, protein-calorie malnutrition, relative insulin deficiency/resistance, and increased counterregulatory hormones driving lipolysis, ketogenesis, and gluconeogenesis. Unlike typical DKA, glucose levels may remain near normal because glucose utilization is relatively preserved while glycosuria still occurs.<br /><br />Treatment began on POD 3 with dextrose-containing IV fluids plus insulin, along with bicarbonate-containing crystalloid for acidosis. By POD 5, the anion gap closed and ketosis resolved; by POD 6, tachycardia, PVCs, and glucosuria improved.<br /><br />Take-home points: consider euglycemic ketoacidosis in postoperative patients with high anion gap metabolic acidosis and ketosis even when glucose is <200 mg/dL, especially in patients with prediabetes or malnutrition. Hospital medicine co-management can be valuable in recognizing and treating these diagnostic challenges.

Asset Subtitle

Aditya J. Ullal

Meta Tag

Author List Aditya J. Ullal, Prashant Patel, Robert Rushakoff

Category Clinical Vignettes

Concept Euglycemic Diabetic Ketoacidosis

Concept Ketoacidosis

Concept Near-Normal Blood Glucose

Concept Ketosis

Concept Acidemia

Distinguished Non-Finalist

Presenter Organization University of California, San Francisco

Presenting Author Aditya J. Ullal

Track Adult

Keywords

euglycemic ketoacidosis

postoperative acidosis

high anion gap metabolic acidosis

beta-hydroxybutyrate

ketonuria

glucosuria

prediabetes

malnutrition

shoulder arthroplasty

insulin and dextrose therapy

Euglycemic Diabetic Ketoacidosis

Ketoacidosis

Near-Normal Blood Glucose

Ketosis

Acidemia