Mismanagement of Diabetic Ketoacidosis Leads to Patient Fatality

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.

Question(s) For Expert Witness

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

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

Expert Witness Response E-021185

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. 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.