Ketoacidosis Is Bariatric Surgery Risk in Type 1 Diabetes

Miriam E Tucker

February 08, 2016

Diabetic ketoacidosis (DKA) appears to be a fairly common adverse event following bariatric surgery in patients with type 1 diabetes and may also occur rarely in insulin-deficient patients with type 2 diabetes, according to new findings from a single bariatric surgery center.

Data from 10 years of experience at the Cleveland Clinic — the largest case series of its kind to date — were published online January 28 in Diabetes Care by Ali Aminian, MD, staff surgeon at the clinic's Bariatric and Metabolic Institute, and colleagues.

"Bariatric surgery can lead to significant weight loss and improved insulin requirements and glycemic status of patients with obesity and type 1 diabetes….Surgeons, anesthesiologists, and endocrinologists should be aware of the risk of DKA in these patients, and surgeons should involve endocrinologists in the perioperative management of these patients to adjust their insulin," Dr Aminian told Medscape Medical News.

Precipitating Factors: Inadequate Insulin, Noncompliance, or Infection

From 2005 through 2015, the researchers identified a total of 12 patients who developed DKA within 90 days following bariatric surgery, at a median of 12 days. Eight of the patients had type 1 diabetes and four had type 2 diabetes.

Those numbers corresponded to incidences of 25% of the 32 total type 1 patients who underwent bariatric surgery during the study period and 0.2% of the approximately 3000 total type 2 patients.

Most of the DKA in the type 1 patients was moderate to severe, while in the type 2 patients it was milder, Dr Aminian noted.

All but one of the patients were taking insulin prior to surgery, and all had poor glycemic control, with a median HbA1c of 9.3%. Three patients had a past history of DKA, and one developed DKA twice postsurgery. Nausea, vomiting, and abdominal pain were the most common presenting symptoms.

Inadequate insulin therapy or noncompliance was the precipitating factor in eight of the 12 cases. In three of these, DKA developed in the immediate postoperative period in the hospital, possibly due to a combination of insulin undertreatment and surgical stress.

In some of these cases, patients had been inappropriately instructed by a member of the surgical team to withhold basal insulin the morning of surgery, Dr Aminian noted, adding that all team members have since been educated about the need for insulin optimization prior to surgery.

Infection was a precipitating factor for DKA in four (33%) of the patients, and poor oral intake could have been a contributing factor in three (25%) patients.

All patients were medically managed with insulin infusion. Two required intubation and mechanical ventilation, two experienced acute kidney injury, and one each had deep vein thrombosis, aspiration pneumonia, and iatrogenic pneumothorax. None died.

Six Key Points to Reduce Risk of DKA in Bariatric Surgery

Based on this experience, Dr Amanian and colleagues have devised six key points applying to all insulin-treated patients undergoing bariatric surgery:

  1. High risk patients — particularly poorly controlled patients with type 1 diabetes — should be informed about warning symptoms, signs, and predisposing factors of postoperative DKA.

  2. These predisposing factors include anesthesia and surgical stress, abrupt discontinuation of insulin or inadequate treatment in the perioperative period, postoperative infection, prolonged poor oral intake, and severe dehydration.

  3. Preventive measures include optimizing glycemic control before surgery, not withholding basal insulin on the morning of surgery, and keeping the patients on insulin intravenous infusion protocols in the perioperative period.

  4. Endocrinologists and diabetes nurse practitioners should be involved in the adjustment of basal insulin dosage before surgery when the patient is on a low-calorie diet (usually beginning 2 weeks prior) and also in the immediate postoperative period and after hospital discharge. Insulin dose adjustment may also be necessary if infection develops postsurgery.

  5. Recognition that postbariatric surgery DKA can cause abdominal pain, nausea, and vomiting should prevent unnecessary imaging studies to rule out intra-abdominal surgical complications such as leaks or abscess.

  6. Early detection and aggressive diabetes care are needed to treat this serious adverse event.

"If we manage those patients appropriately, the incidence of DKA will be lower," Dr Aminian said.

The study authors have no relevant financial relationships.

Diabetes Care. Published online January 28, 2016. Article

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