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HCC Surveillance — RACP Adult Medicine MCQ

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HardGastroenterologyHCC SurveillanceRACP Adult Medicine

A 64-year-old taking empagliflozin undergoes urgent laparotomy after prolonged fasting. Twelve hours later she is tachypnoeic and nauseated. Glucose is 9.8 mmol/L, bicarbonate 13 mmol/L and anion gap 24 mmol/L. What is the most appropriate immediate response?

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Reveal the answer and explanation

Correct answer: C — Stop empagliflozin; measure ketones and start intravenous insulin with glucose and fluids

Explanation lettering: B = shown as A · E = shown as B · D = shown as C · C = shown as D · A = shown as E

D is correct. Perioperative SGLT2-associated ketoacidosis may occur with only modest glucose elevation; the high-anion-gap acidosis requires urgent ketone confirmation while treatment starts with drug cessation, intravenous insulin plus glucose, fluids and electrolyte monitoring. A gives supportive fluid but does not stop ketogenesis. B is inadequate and perpetuates the trigger. C misclassifies a high-risk drug-associated acidosis as simple fasting ketosis. E may transiently change bicarbonate but does not stop ketogenesis and is not definitive therapy.

Reference: Australian Diabetes Society and ANZCA, Perioperative diabetes and hyperglycaemia guidelines (adults): https://www.diabetessociety.com.au/wp-content/uploads/2023/03/ADS-ANZCA-Perioperative-Diabetes-and-Hyperglycaemia-Guidelines-Adults-November-2022-v2-Final-3.pdf