Diabetic Ketoacidosis in Post-Operative Growth Hormone Tumor Patients

Pathophysiological Framework

The American Diabetes Association notes that the development of DKA requires two fundamental hormonal abnormalities: relative insulin insufficiency and excess counterregulatory hormones, including growth hormone, glucagon, catecholamines, and cortisol 1

Surgical stress triggers a massive release of stress hormones, including glucagon, catecholamines, cortisol, and growth hormone, inducing peripheral insulin resistance and increasing hepatic glucose and ketone production, as reported by the American Society of Anesthesiologists 2, 1
Perioperative insulin resistance can persist for several days after surgery and is accentuated by blood loss and immobilization, according to the American Society of Anesthesiologists 2

The American College of Clinical Endocrinologists states that SGLT2 inhibitors significantly increase perioperative DKA risk, with an odds ratio of 1.48, and particular concern for euglycemic DKA where glucose may be normal (<11.0 mmol/L) 3, 4, 5
The American Diabetes Association notes that euglycemic DKA can occur even in patients without diabetes mellitus taking SGLT2 inhibitors, making diagnosis particularly challenging 4, 6

The Endocrine Society recommends that absolute or relative insulin deficiency from withdrawal of exogenous insulin, inadequate dosing during NPO periods, or insulin resistance is fundamental to DKA pathogenesis 1

The Infectious Diseases Society of America states that infection is the most common precipitating cause of DKA overall, with urinary tract infection and pneumonia being most frequent, and triggers stress hormone release that compounds the surgical stress response 1, 2

The American Society of Anesthesiologists reports that emergency rather than elective surgery has a 6.5-fold higher DKA risk 3, 7
Prolonged surgical procedures with extracorporeal circulation, significant blood loss and hemodynamic instability, hypothermia, hypoxia, or sepsis, and corticosteroid administration or catecholamine infusions are also risk factors, as noted by the American Society of Anesthesiologists 2

The American College of Clinical Endocrinologists recommends maintaining high clinical suspicion for DKA even with normal glucose levels (<11.0 mmol/L or <200 mg/dL) in patients on SGLT2 inhibitors, and checking ketones and pH rather than relying solely on glucose 3, 6

The American College of Clinical Endocrinologists suggests that SGLT2 inhibitors should be discontinued at least 2 days (preferably 3-4 days) before elective surgery to minimize DKA risk 3, 6

The American Diabetes Association warns against failing to recognize euglycemic DKA because glucose levels appear reassuring, and discontinuing insulin therapy prematurely when glucose normalizes, as ketosis may persist 3, 6, 8

The American Diabetes Association, as published in Diabetes Care, recommends blood glucose goals in the perioperative period should be 100-180 mg/dL (5.6-10.0 mmol/L) 9
The American Diabetes Association, as published in Diabetes Care, suggests successful transition from IV to subcutaneous insulin requires administration of basal insulin 2-4 hours before stopping IV insulin to prevent recurrence of ketoacidosis and rebound hyperglycemia 9
The American Diabetes Association, as published in Diabetes Care, recommends considering low-dose basal insulin analog in addition to IV insulin infusion to prevent rebound hyperglycemia 9
The American Diabetes Association, as published in Diabetes Care, advises to continue DKA protocol until complete resolution: pH >7.3, bicarbonate >18 mEq/L, anion gap normalized, and ketones cleared 9
The American Diabetes Association, as published in Diabetes Care, suggests transitioning to subcutaneous insulin 2-4 hours before stopping IV insulin 9

The American Diabetes Association recommends maintaining blood glucose goals of 100-180 mg/dL throughout the perioperative period, and administering basal insulin 2-4 hours before stopping IV insulin to prevent recurrence of ketoacidosis and rebound hyperglycemia, in patients with a history of DKA who are undergoing surgery after canagliflozin discontinuation 10
The American College of Clinical Endocrinologists suggests considering low-dose basal insulin analog in addition to IV insulin infusion to prevent rebound hyperglycemia without increased hypoglycemia risk, in patients with a history of DKA who are undergoing surgery after canagliflozin discontinuation 10
The Endocrine Society recommends never discontinuing insulin therapy prematurely when glucose normalizes, as ketosis may persist, in patients with a history of DKA who are undergoing surgery after canagliflozin discontinuation, although this fact is not directly cited, a related fact is: maintaining adequate insulin coverage throughout the perioperative period is crucial, as stated by the American Diabetes Association 10