(124) From Crisis to Tragedy: Diabetic Ketoacidosis Leading to Brain Death

Introduction: Diabetic ketoacidosis (DKA) is a severe complication of diabetes characterized by high blood glucose, ketosis, and metabolic acidosis. Prompt treatment can improve symptoms, but there are potential catastrophic outcomes like cerebral edema. We report a case of cerebral edema in a 78-year-old male with insulin-dependent diabetes mellitus type 2 and chronic kidney disease stage 4.

Description: The patient presented with unresponsiveness, markedly elevated blood glucose (1150 mg/dL), anion gap of 27, and ketones in urine. Intravenous insulin lispro was administered, and the patient was intubated for airway protection. Gradual reduction of blood glucose over 48 hours resulted in levels of 570 and 300 mg/dL. However, upon discontinuation of sedation, the patient showed neurological deterioration and brain edema on CT scan, with signs of brain death.

Discussion: This case exemplifies brain edema due to rapid correction of severe hyperglycemia in a DKA patient using insulin therapy. Rapid correction can shift fluid from intracellular compartments into the extracellular, leading to cerebral edema. For this particular patient, initial reduction from 1000 to 500 mg/dl may have contributed to his neurological deterioration and brain edema occurrence; furthermore, chronic kidney disease could have impaired their ability to excrete excess glucose during hyperglycemic periods allowing glucose load accumulation during hyperglycemic phases adequately. Brain edema and subsequent brain death highlight the need for careful management in treating hyperglycemia, particularly within DKA. Monitoring fluid and electrolyte balance as well as gradual correction should be utilized to lower risks associated with cerebral edema; identification of patients at greater risk - for instance those suffering severe hyperglycemia or altered mental status is paramount in order to ensure appropriate intervention. This case report showcases the potential complications associated with treating severe hyperglycemia in DKA patients, which could potentially result in brain edema and, eventually, death.