Emerging cause of acute metabolic acidosis in the ICU

Abstract

Background Metabolic acidosis is a frequent finding in patients admitted to in the intensive care unit (ICU). Starvation ketoacidosis (SKA) is an often urecognized clinical condition, that occurs after the body is deprived of glucose as the primary source of energy for a prolonged time, and fatty acids replace glucose as the major metabolic fuel, leading to the production of ketone bodies, causing metabolic acidosis.

We conducted a retrospective observational study; we screened medical records of patients admitted to ICU from 2022/10/10 to 2023/04/10, including patients with metabolic acidosis with ketonuria detected by urine samples or urine stick positivity treated with glucose solutions or enteral/oral nutrition within 2 hours of diagnosis. The primary outcome was to evaluate the incidence of ketoacidosis in critically ill patients; the secondary outcome was to evaluate the impact of ketoacidosis on hemodynamic instability and the role of early treatment in reducing complications and days of hospitalization in ICU. 

Results In the study period 574 patients were admitted to the ICU, 90 patients with diagnosis of ketoacidosis (15,67%) of which, 16 patients met inclusion criteria. Of these patients 9 were hemodynamically stable and 7 unstable. The unstable patients had a mean norepinephrine support of 0,22 mcg/kg/min. Unstable patients had lower BE value than stable patients (-8,6 vs -4, p =0,09), lower pH (7,30 vs 7,34, p=0,26), significantly lower serum albumin (23,3 vs 30,4, p =0,04) and lower HCO3- (18,4 mmol/L vs 22,6, p = 0,04). No statistically significant differences were found in the absolute value of ketonuria (unstable 48,3 vs stable 51,8, p= 0,90) or in the lactate levels at admission.

Conclusion In our analysis we found that acidosis can lead to transient hemodynamic instability, early treatment could avoid several complications and could short ICU length of stay or unnecessary ICU admission.