Case of the Month #44 High Anion Gap Metabolic Acidosis

Published 12/10/2023

How should this case be managed?


An ABCDE approach to initial assessment and management should be adopted.

Given the symptoms and history, it is not unreasonable to investigate other causes of organ dysfunction such as pancreatitis and aortic pathology with blood tests and imaging if safe to do so.

Fundamental principles of managing DKA are provided by the Joint British Diabetes Societies:

  1. Intravenous fluid resuscitation (often with 0.9% NaCl)
  2. Intravenous insulin (as fixed rate insulin infusion)
  3. Electrolyte management

Specific considerations need to be given to this case:

  • Background 10% glucose should be commenced immediately given the starting blood glucose is <14 mmol/L.
  • If blood glucose falls despite commencing 10% glucose, a lower fixed rate insulin infusion (0.05 units/kg/hr) should be considered to reduce the risk of hypoglycaemia.
  • Given this patient’s age and cardiac history, early referral to critical care should be made.
  • The patient’s cardiac history including treatment for impaired ventricular function and a cardiac resynchronisation device increases the risk of fluid overload with the normal regimen provided in guidelines.


A referral should be made to the inpatient diabetes specialist team.

The SGLT2-inhibitor should not routinely be recommenced on resolution of the DKA.

The reaction should be reported by the ‘Yellow Card’ scheme run by the MHRA.