Objective : Adrenal insufficiency is a known side effect of etomidate use. Expert opinion suggests coadministration of glucocorticoids to avoid this effect. This case reports the development of ketoacidosis post rapid sequence induction using etomidate with co-administration of hydrocortisone and discusses the pathophysiology and likelihood of two important differentials: fasting ketoacidosis and euglycemic diabetic ketoacidosis (DKA) in a type II diabetic (T2DM). This case highlights an interesting side effect of concomitant steroid use with etomidate.
Methods : NA
Results : NA
Discussion : A 71 year old Caucasian male with T2DM and no history of alcohol use was admitted for community acquired pneumonia after symptoms of fever, shortness of breath and cough with a new infiltrate on chest x-ray. His glycemia had been well controlled with with oral hypoglycemics. The patient subsequently developed respiratory distress with impending respiratory failure and was intubated with rapid sequence intubation using Etomidate and Rocuronium with co-administration of Hydrocortisone 50mg iv q 6h. His oral hypoglycemics were stopped and an insulin sliding scale started. Laboratory parameters 12 hours post intubation showed: pH7.33, pCO2 33.1, pO2 86.1, HCO3 20.5, serum β- hydroxybutyrate >4 mmol/L, anion gap 21, blood glucose 160mg/dl. Serum lactate was normal, alcohol level was undetectable. Hydrocortisone was discontinued. A 5% dextrose infusion with insulin regimen led to the closure of his anion gap and improvement in ketone levels.
Etomidate is used for rapid-sequence intubation due to its minimal effect on vascular tone and myocardial depression in critically ill patients, despite its risk of 11β-hydroxylase inhibition and adrenal insufficiency. Expert opinion suggests a glucocorticoid course after intubation to avoid these effects. The increased counterregulatory hormones (catecholamines, glucagon, cortisol) during this concurrent illness, augmented by the exogenous hydrocortisone therapy likely increased lipolysis and ketone generation leading to ketoacidosis. While steroids can worsen insulin resistance resulting in hyperglycemia, the fasting state, in the presence of continued insulin administration led to normoglycemia in this patient. The mild reductions in bicarbonate and pH made euDKA less likely.
Conclusion : While a distinction should be made between fasting ketoacidosis and euDKA, the diabetic patient may be at risk of either. There is considerable overlap between starvation ketoacidosis and euDKA as the relative normoglycemia in euDKA occurs as a result of prolonged fasting. Both remain important differentials when faced with a diabetic in euglycemic ketoacidosis with no alcohol use history.
Afe Alexis– Resident, University of Miami/ Jackson Memorial Hospital, Miami, Florida
University of Miami/ Jackson Memorial Hospital
Dr. Afe Alexis completed her medical training at the University of the West Indies in 2011. In 2015, she was awarded a Commonwealth scholarship to pursue a Masters of Science degree in Gerontology at the University of Southampton UK. She in currently an Internal Medicine resident at Jackson Memorial Hospital.