Hypernatremia in Diabetic Ketoacidosis: Rare Presentation and a Cautionary Tale

Ibarra, Gabriel Lara; Majmundar, Monil; Pacheco, Enrique; Zala, Harshvardhan; Chaudhari, Shobhana

doi:10.7759/cureus.11841

Cited by 8 publications

(15 citation statements)

References 6 publications

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“…The appearance of hypernatremia in DKA can be attributed to a fluid imbalance. As significant volumes of free fluid are lost (most commonly by polyuria), electrolyte loss (through vomiting and diarrhea) may lag behind, leading to a very unusual occurrence of hypernatremia with osmolytic imbalance[ 4 ]. Although such cases of DKA-induced hypernatremia are infrequent, a 2019 paper reviews the cases of two female patients found to be suffering from hypernatremia secondary to DKA after complaints of altered mental status and other symptoms[ 5 ].…”

Section: Discussionmentioning

confidence: 99%

Severe hypernatremia in hyperglycemic conditions; managing it effectively: A case report

Lathiya¹,

Errabelli²,

Cullinan³

et al. 2023

World J Crit Care Med

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BACKGROUND Diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS) are common acute complications of diabetes mellitus with a high risk of mortality. When combined with hypernatremia, the complications can be even worse. Hypernatremia is a rarely associated with DKA and HHS as both are usually accompanied by normal sodium or hyponatremia. As a result, a structured and systematic treatment approach is critical. We discuss the therapeutic approach and implications of this uncommon presentation. CASE SUMMARY A 62-year-old man with no known past medical history presented to emergency department with altered mental status. Initial work up in emergency room showed severe hyperglycemia with a glucose level of 1093 mg/dL and severe hypernatremia with a serum sodium level of 169 mEq/L. He was admitted to the intensive care unit (ICU) and was started on insulin drip as per DKA protocol. Within 12 h of ICU admission, blood sugar was 300 mg/dL. But his mental status didn’t show much improvement. He was dehydrated and had a corrected serum sodium level of > 190 mEq/L. As a result, dextrose 5% in water and ringer's lactate were started. He was also given free water via an nasogastric (NG) tube and IV Desmopressin to improve his free water deficit, which improved his serum sodium to 140 mEq/L. CONCLUSION The combination of DKA, HHS and hypernatremia is rare and extremely challenging to manage, but the most challenging part of this condition is selecting the correct type of fluids to treat these conditions. Our case illustrates that desmopressin and free water administration via the NG route can be helpful in this situation.

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Section: Discussionmentioning

confidence: 99%

Severe hypernatremia in hyperglycemic conditions; managing it effectively: A case report

Lathiya¹,

Errabelli²,

Cullinan³

et al. 2023

World J Crit Care Med

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“…While poor intake and deconditioning from an infection likely played a role, it is still uncommon for a DKA patient to present with hypernatremia. The proposed mechanism for hypernatremia in DKA emanates from excessive osmotic diuresis that leads to a volume-depleted state [ 8 ]. The patient’s home regimen included hydrochlorothiazide.…”

Section: Discussionmentioning

confidence: 99%

“…Patients with new-onset diabetes were more likely to have hypernatremia than those who were previously known to be diabetic [ 9 ]. It has been proposed that prolonged DKA eventually leads to loss of hypotonic urine with increased glomerular filtration rate [ 8 , 9 ]. In pediatric populations, the presence of hypernatremia in DKA has been associated with the ingestion of carbohydrate-rich soft drinks [ 10 ].…”

Section: Discussionmentioning

confidence: 99%

Hypernatremia in Diabetic Ketoacidosis: A Rare Metabolic Derangement Requiring a Cautionary Approach in Fluid Resuscitation

Zardoost¹,

Khan²,

Wehrum³

et al. 2023

Cureus

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Diabetic ketoacidosis (DKA) with hypernatremia is an atypical metabolic derangement that warrants additional consideration in choosing IV fluids. Our patient, a middle-aged male with a history of insulindependent diabetes mellitus type 2 and hypertension, presented with DKA and hypernatremia in the setting of poor intake, community-acquired pneumonia (CAP), and COVID-19. DKA and hypernatremia led to a meticulous approach to fluid resuscitation, where a crystalloid solution was the choice in treating and preventing exacerbation of either condition. Successful treatment of these conditions requires understanding the unique pathophysiology, which demands further research on management.

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“…Moreover, our lactate sensing scheme is generalizable to additional oxidases and their corresponding analytes including glucose and alcohol. , The addition of these analytes can broaden the applicability of the MSF to other medical conditions. For example, continuous monitoring of sodium, pH, lactate, oxygen, and glucose in individuals experiencing diabetic ketoacidosis can diagnose dehydration (loss of sodium), ketoacidosis (high glucose and low pH), and ischemia (low oxygen and high lactate), directing healthcare professionals toward a specific mode of intervention. − An expanded MSF could also be applicable beyond the medical field, such as in bioreactors for protein expression, agriculture, water management, and food industry, where sensing pH, glucose, and sodium would provide vital information to each respective field. − …”

Section: Discussionmentioning

confidence: 99%

Transcutaneous Flexible Sensor forIn VivoPhotonic Detection of pH and Lactate

Nguyen

Berg

et al. 2022

ACS Sens.

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Clinical research shows that frequent measurements of both pH and lactate can help guide therapy and improve patient outcome. However, current methods of sampling blood pH and lactate make it impractical to take readings frequently (due to the heightened risk of blood infection and anemia). As a solution, we have engineered a subcutaneous pH and lactate sensor (PALS) that can provide continuous, physiologically relevant measurements. To measure pH, a sheet containing a pH-sensitive fluorescent dye is placed over 400 and 465 nm light-emitting diodes (LEDs) and a filter-coated photodetector. The filter-coated photodetector collects an emitted signal from the dye for each LED excitation, and the ratio of the emitted signals is used to monitor pH. To measure lactate, two sensing sheets comprising an oxygen-sensitive phosphorescent dye are each mounted to a 625 nm LED. One sheet additionally comprises the enzyme lactate oxidase. The LEDs are sequentially modulated to excite the sensing sheets, and their phase shift at the LED drive frequency is used to monitor lactate. In vitro results indicate that PALS successfully records pH changes from 6.92 to 7.70, allowing for discrimination between acidosis and alkalosis, and can track lactate levels up to 9 mM. Both sensing strategies exhibit fast rise times (< 5 min) and stable measurements. Multianalyte in vitro models of physiological disorders show that the sensor measurements consistently quantify the expected pathophysiological trends without cross talk; in vivo rabbit testing further indicates usefulness in the clinical setting.

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Hypernatremia in Diabetic Ketoacidosis: Rare Presentation and a Cautionary Tale

Abstract: Ibarra et al. This is an open access article distributed under the terms of the Creative Commons Attribution License CC-BY 4.0., which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Cited by 8 publications

References 6 publications

Severe hypernatremia in hyperglycemic conditions; managing it effectively: A case report

Severe hypernatremia in hyperglycemic conditions; managing it effectively: A case report

Hypernatremia in Diabetic Ketoacidosis: A Rare Metabolic Derangement Requiring a Cautionary Approach in Fluid Resuscitation

Transcutaneous Flexible Sensor forIn VivoPhotonic Detection of pH and Lactate

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