Starvation ketoacidosis

We read with interest the recent case report by Yeow et al. ¹ of a 65-year-old female who developed starvation ketoacidosis perioperatively following an extended period of poor oral intake. The authors noted that euglycaemic ketoacidosis in non-diabetic patients is very rarely reported and that it is important to be aware of the condition.

Perhaps the most common factor that predisposes to starvation ketoacidosis in otherwise healthy individuals is pregnancy, which the authors do not mention. It has long been known that accelerated ketone production following fasting is seen in normal pregnancy. ² We have recently reported a number of cases of starvation ketoacidosis in pregnant women without hyperglycaemia. ³ It typically occurs in the third trimester following a short history of reduced oral intake. We have also described this condition in pregnant women with pancreatitis and in one woman after commencement of olanzapine during pregnancy.^4,5 Many of these women were admitted to intensive care units and several had emergency deliveries in the absence of a clear diagnosis. On the other hand, in those in whom the diagnosis was recognised, treatment with dextrose alone often appeared to be sufficient to bring about cure. The possible underlying mechanisms are discussed at length elsewhere, but probably involve stimulation of endogenous insulin secretion. ³

The authors discuss the difficulty in interpreting the acid-base and electrolyte picture in their patient. A normal anion gap has been reported in ketoacidosis of various aetiologies, not only due to fluid resuscitation but also as a result of disturbed renal electrolyte handling in the setting of ketonuria. This was a finding in many of our obstetric cases. It is essential for clinicians not to be misled by the normal anion gap, which may conceal significant circulating unmeasured organic acids.

We agree with the authors that starvation ketoacidosis is under-recognised. Intensive care physicians and anaesthetists who encounter pregnant patients with a severe metabolic acidosis should consider this diagnosis early. Prompt recognition and treatment with simple measures may avoid admission to an intensive care unit altogether and prevent unnecessary interventions including emergency delivery.