Hiroshi Ueta

444: STARVATION-INDUCED SEVERE KETOACIDOSIS IN A PATIENT WITH A NEUROMUSCULAR DISORDER

www.ccmjournal.org Critical Care Medicine • Volume 46 • Number 1 (Supplement) Learning Objectives: Ketoacidosis, a form of high anion gap metabolic acidosis due to the accumulation of ketone bodies, is often encountered in the critical care setting. Its commonest cause is diabetic ketoacidosis; non-diabetic causes are starvation-induced ketosis and alcoholic ketoacidosis. Although generally mild, starvation-induced ketosis is known to cause severe ketoacidosis under conditions such as pregnancy, eating disorders, and extreme exercise. We present a case of starvation-induced severe ketoacidosis in a patient with neuromuscular disorder but without a history of diabetes, drinking or eating disorder. Methods: The patient was a 29-year-old Japanese woman with genetically confirmed spinal muscular atrophy type 2. She had loss of muscle mass and needed assistance with all activities of daily living except feeding. Her BMI was 13.3 kg/m with no significant change in the last 3 years. She was hospitalized due to aspiration pneumonia and her symptoms improved after intravenous antibiotic therapy. On the 7th hospital day, she experienced abdominal pain, nausea, and vomiting. An arterial blood gas revealed severe metabolic ketoacidosis (pH 6.98, PaCO 2 21.9 mmHg, PaO 2 104.6 mmHg, HCO 3 4.9 mmol/L, Anion Gap 17.7 mmol/L, Glucose 115 mg/dL, Lactate 0.5 mmol/L). Additional laboratory tests were remarkable only for elevated serum and urinary ketone levels, with normal levels of HbA1c and C-peptide. She denied a history of alcohol, use of any health supplements, or pregnancy. Having excluded other causes, we diagnosed starvation-induced ketoacidosis. She was treated with intravenous 50% dextrose and her pH improved to 7.48 by the next morning. Results: Although starvation-induced ketosis is seldom suspected to cause severe ketoacidosis in clinical practice, patients with neuromuscular disorders are at a risk of developing severe ketoacidosis because the reduced muscle mass decreases the availability of amino acids for gluconeogenesis, resulting in ketone body production. Lower muscle mass also leads to less ketone body excretion. Also, altered fatty acid metabolism and endocrine imbalance promote ketosis, especially in situations such as infection and other illness. This case highlights that ketoacidosis can be life threatening in neuromuscular disorders and so suspicion and early recognition are important.

1246: CORE PERIPHERAL TEMPERATURE GRADIENT-GUIDED HEMODYNAMIC MANAGEMENT AFTER CARDIAC SURGERY

www.ccmjournal.org Critical Care Medicine • Volume 46 • Number 1 (Supplement) Learning Objectives: Core-Peripheral Temperature Gradient (CPTG) has become common practice as a noninvasive method of monitoring hemodynamic status in critically ill patients, but the reliability of CPTG is controversial. The management concept not to increase the CPTG might be useful for adequate organ perfusion. However, this strategy might also cause volume overload which is related to poor outcomes. Therefore, we investigated the association of the increase of CPTG and postoperative complications including AKI, prolonged intubation and prolonged hospitalization after cardiac surgery. Methods: Patients (over 18 yrs) who underwent cardiac surgery were retrospectively reviewed to investigate whether the increase of postoperative CPTG had an association with complications. The blood temperature measured by pulmonary artery catheter was defined as the core temperature. The palm temperature was defined as the peripheral temperature. The CPTG was measured as the difference between the core and the peripheral temperature at ICU admission and after three hours. The candidates for factors of complications were examined by multivariable logistic regression analysis. Results: From July to December 2016, 157 patients who underwent cardiac surgery at our institution were enrolled in this study. Patients receiving maintenance dialysis and without pulmonary artery catheter insertion were excluded. Finally, 98 patients were reviewed retrospectively. Among them, AKI occurred in 54 cases (55.1%), prolonged intubation (over 6 hrs) occurred in 57 cases (58.1%), and prolonged hospitalization (over 14 days) occurred in 44 cases (44.9%). The multivariable logistic regression analysis for factors of complications revealed that the increase of CPTG had significant association with AKI(p = 0.026) but had no association with prolonged intubation(p = 0.77) and prolonged hospitalization(p = 0.59). Conclusions: Hemodynamic management not to increase the CPTG might be useful strategy for preventing AKI after cardiac surgery without wet-status associated complications such as prolonged intubation time nor hospitalization period.