LAUSR

Bariatric surgery has been proven to be an effective solution for morbid obesity with type 2 diabetes mellitus (T2DM), and such patients usually receive oral hypoglycemia agents or insulin for blood sugar control prior to surgery [1]. Though the occurrence of euglycemic diabetic ketoacidosis (DKA) is not clinically infrequent especially for those on treatment with sodium-glucose cotransporter 2 (SGLT2) inhibitor, reports of DKA after bariatric surgery are limited and most of the available reports discussed type I diabetes [1–3]. Herein, we report a T2DM patient (without SGLT2 inhibitor use) who developed euglycemic DKA soon after Rouxen-Y gastric bypass (RYGB). Moreover, the postoperative course was complicated with an attack of chronic gouty arthritis and acute exacerbation of chronic kidney disease, but eventually the patient made a full recovery. A 52-year-old, morbidly obese male patient (body weight 110.3 kg; body mass index 37.7 kg/m), with newly diagnosed T2DM (glycated hemoglobin 9.5%; homeostatic model assessment of insulin resistance 8.2) and poly-morbidities (hypertension, dyslipidemia, hyperuricemia with left ankle tophi, chronic kidney disease, and non-alcoholic fatty liver disease), was referred to our hospital for weight loss surgery. For blood sugar control, only metformin was prescribed (500 mg thrice a day) instead of a SGLT2 inhibitor. The patient had also taken diclofenac occasionally to relieve pain from chronic gouty arthritis over the bilateral feet. Laparoscopic RYGB was uneventfully performed on the 2nd day after admission with an estimated blood loss of 30 mL. The operation time was 210 min, and the intra-abdominal pressure of the pneumoperitoneum was up to 15–17 mmHg during the surgery. On postoperative day 1, the patient started sipping water without obvious discomfort, and regular insulin was continuously infused at a rate of 1.25 U/h (blood sugar level was between 192 and 205 mg/dL) (Fig. 1). However, a spiking fever (39.3°C) occurred in the evening with a significant decrease in urine amount (from 3010 to 480 mL/day). Meanwhile, the patient also presented with tachypnea (26 breaths per minute) and tachycardia (123 beats per minute). No peritoneal sign or chest tightness was reported. The laboratory studies showed leukocytosis, elevated level of procalcitonin (3.4 ng/mL), and deteriorated renal function (creatinine 3.99 mg/L) (Table 1). Moreover, the blood gas analysis demonstrated metabolic acidosis with respiratory compensation (Table 1). The blood sugar still remained at a marginally higher level (219 mg/dL). Upon arriving at the intensive care unit, hypotension developed (72/49 mmHg) and fluid resuscitation, vasopressor, and empirical antibiotics (imipenem + cilastatin) were administered for possible occult intra-abdominal infection. On the following day (postoperative day 2), blood ketone levels were examined for fluctuating blood sugar levels, which disclosed a positive result (6.1 mmol/L) in favor of DKA. Regular insulin pump was titrated up to 2 U/h accordingly. Thereafter, the fever subsided and urine output increased gradually with concomitant recovery of blood * Po-Chih Chang [email protected]