Fatal Cerebral Edema in a Young Adult with Diabetic Ketoacidosis: Blame the Bicarbonate?

Abstract

Cerebral edema is a devastating complication of DKA which is extremely rare in adults but is the leading cause of diabetes-related death in the pediatric population. Newly diagnosed diabetes, younger age, first episode of DKA, severity of DKA at presentation, and administration of bicarbonate are predictive of cerebral edema in DKA. We present a case of a young adult with DKA as the presenting symptom of diabetes, whose clinical course was complicated by renal failure, refractory shock, and cerebral edema. This case addresses the controversy surrounding bicarbonate therapy in DKA and its possible role in the development of a rare fatal complication of DKA.

Diabetic Ketoacidosis Complicated by a Brain Death

“…The affected population is usually younger than 20 years with most cases occurring in DKA [ 6 ]. The most common risk factors for developing CE are newly diagnosed DM, young age, first episode of DKA, severity of DKA, and administration of bicarbonate [ 3 ].…”

“…Diabetic ketoacidosis (DKA) is an acute, life-threatening complication of diabetes mellitus (DM) occurring more commonly in type one DM. DKA is characterized by elevated blood glucose, anion gap metabolic acidosis, and ketonemia [ 1 - 3 ]. Osmotic diuresis due to hyperglycemia leads to volume depletion and electrolyte imbalance which are the hallmark of the disease process [ 3 ].…”

“…DKA is characterized by elevated blood glucose, anion gap metabolic acidosis, and ketonemia [ 1 - 3 ]. Osmotic diuresis due to hyperglycemia leads to volume depletion and electrolyte imbalance which are the hallmark of the disease process [ 3 ]. The backbone of management in DKA consists of fluid resuscitation, electrolyte repletion, and hyperglycemia correction by insulin infusion.…”

Predisposing Factors of Cerebral Edema in Pediatric Diabetic Ketoacidosis: A Systematic Review

“…DKA is the leading cause of death in children with type 1 diabetes (19,23,(27)(28)(29), which is caused by severe insulin deficiency in either previously undiagnosed patients with type 1 diabetes or individuals with known diabetes who deliberately or inadvertently take insufficient amounts of insulin (27,29,30). It is a life-threatening complication (31,32) that is diagnosed with hyperglycemia, acidosis, and ketosis (33)(34)(35) and rapidly leads to severe dehydration and mental state changes caused by cerebral edema (36). The ultimate goal of DKA treatment is to correct hyperglycemia, ketoacidosis, and dehydration, and prevent treatment complications (32), including cerebral edema (33).…”

“…It is a life-threatening complication (31,32) that is diagnosed with hyperglycemia, acidosis, and ketosis (33)(34)(35) and rapidly leads to severe dehydration and mental state changes caused by cerebral edema (36). The ultimate goal of DKA treatment is to correct hyperglycemia, ketoacidosis, and dehydration, and prevent treatment complications (32), including cerebral edema (33). Although diabetic ketoacidosis is not the most common acute complication of type 1 diabetes in children and adolescents (37), the cerebral edema caused by it is the most common cause of death in children with DKA, which is associated with significant morbidity (21% to 35%) and mortality (30-60%) (24,38,39).…”