Mismanagement of Diabetic Ketoacidosis Leads to Patient Fatality

Case Overview

This case involves a middle-aged male with a past medical history of cancer who presented to the emergency room with multiple symptoms and was diagnosed with diabetic ketoacidosis. He was intubated, admitted to the ICU, and placed on pressors. The patient was placed on hypertonic saline for some time during his stay in the ICU. After a few days in the ICU, the patient did not gain consciousness after weaning from sedation. A CT revealed the possibility for a hypoxic-ischemic event, as well as concern for herniation. The patient eventually passed away due to significant brain injuries.

Questions to the Critical Care Medicine expert and their responses

Please describe your experience in the management of DKA in the ICU setting.

I am Vice chairman and professor of critical care medicine at my institution. I frequently manage adult patients in the Intensive Care Unit with diabetic ketoacidosis.

What are the possible complications of placing a patient on hypertonic saline and how can they be prevented?

I also have extensive experience using hypertonic saline for hyponatremia and for various neurologic emergencies and I frequently lecture fellow and residence on appropriate management of hypertonic saline infusions. Patients with diabetic ketoacidosis are usually highly volume depleted and have severe electrolyte abnormalities that are generally corrected with isotonic saline first, not hypertonic saline. A diagnosis of hyponatremia sometimes is misinterpreted from lab values in the context of severe hyperglycemia and this may cause a clinician to mistakenly administer hypertonic saline. If patients are administered hypertonic saline they need to be on a very strict and frequent laboratory monitoring protocol to ensure that there are not sudden shifts in the serum sodium value. From the brief description of the case, there seems to be mismanagement of saline administration.

About the expert

This expert has nearly 15 years of experience in the field of critical care medicine. He earned his BA in English literature from Dartmouth College, followed by both his MA in epidemiology and biostatistics and his MD from the University of California, San Francisco. He then remained at the University of California, San Francisco, where he completed a residency in internal medicine, a fellowship in pulmonary and critical medicine, and a second fellowship in clinical ethics. Today, this expert is board certified in critical care medicine and is a member of several professional organizations, including the Society for Critical Care Medicine and the American Thoracic Society. He is also very active in academia, having published over 160 peer-reviewed articles, 24 textbook chapters, and 4 textbooks. Moreover, he has been the investigator or co-investigator for over a dozen clinical trials. Previously, he was the director of the clinical ethics core, an assistant professor of medicine, and an attending physician in the adult ICU at the University of California, San Francisco, as well as an associate professor of critical care medicine at the University of Pittsburgh. Currently, he is a professor and the endowed chair of ethics for critical care medicine, the director of ethics and decision-making in critical illness, and the vice-chair of faculty development in critical care medicine at a major medical school in Pennsylvania. He is also an attending physician in the adult ICU at a major university-affiliated medical center in Pennsylvania.

E-021185

Specialties:

Critical Care Medicine