Excessive Sodium Bicarbonate Infusion May Result in Osmotic Demyelination Syndrome During Treatment of Diabetic Ketoacidosis: A Case Report

Abstract

Introduction We present a case wherein diabetic ketoacidosis (DKA) was treated with a large amount of sodium bicarbonate and potassium chloride, resulting in the development of osmotic demyelination syndrome (ODS). Case presentation Our patient was a 29-year-old male with a history of post-surgical repair for ventricular septal defect. Upon arrival, the patient’s Glasgow Coma Scale (GCS) score was E2M4V3. Laboratory examinations revealed leukocytosis, severe metabolic acidosis, hypokalemia, and hyperglycemia. His consciousness status and hemodynamics improved after resuscitation (GCS: E3M6Ve). However, they declined at the 40th hour of admission and dropped to GCS E2M2Ve. Magnetic resonance imaging revealed multifocal abnormal signal intensity changes in the whole brain stem. The diagnosis of type 1 diabetes mellitus was made during the hospitalization period. The patient exhibited improved consciousness status after 17-day medical care at the ICU. Conclusions We recommend that in the case of DKA, the correction of hypokalemia should be prioritized during treatment. Sodium bicarbonate infusion should be reserved for pH < 6.9. In addition, close monitoring of the serum sodium level and prompt actions to lower it if it exceeds the threshold may be necessary.

Central pontine myelinolysis mimicking glioma in diabetes: A case report

“…Currently, CPM is considered a rare complication of uncontrolled diabetes, which is supported by several reports in patients diagnosed with CPM secondary to hyperosmolar hyperglycemia[ 5 - 9 ]. In one such case report[ 5 ], a 28-year-old female with type 1 diabetes presented with an asymptomatic pontine lesion (named “asymptomatic pontine lesion”) and diabetic amyotrophy following rapid treatment of poor glycemic control.…”

Comment on “Excessive Sodium Bicarbonate Infusion May Result in Osmotic Demyelination Syndrome During Treatment of Diabetic Ketoacidosis: A Case Report” by Hsieh et al.

“…Although we find the possible correlation between ODS and hypokalemia mentioned by the authors [1] very fascinating, we would like to emphasize the importance of proper management of DKA and hyperglycemic hyperosmolar state (HHS), with a focus on the fluctuations of P osm and P Na . In our previous works, we set up several mathematical models that allowed us to develop a quantitative approach for the treatment of HHS with the aim of limiting the risk of harmful complications, notably ODS [3, 4].…”

“…We read with great interest the case report recently published in Diabetes Therapy by Hsieh et al [1], describing a paradigmatic case of diabetic ketoacidosis (DKA) complicated by osmotic demyelination syndrome (ODS). The initial estimate was based on a plasma sodium concentration ( P Na ) correction factor of 1.6 mEq/L every 100 mg/dL increase in plasmatic glucose above 100 mg/dL, but more recent evidence supports the use of higher correction factors (up to 4 mEq/L) [2].…”

Prolonged Altered Mental Status in a Diabetic Hemodialysis Patient

“…It was first described in 1959 by Adams et al in alcoholic and malnourished patients [ 2 ]. It is a rare but life-threatening neurological disorder, which is commonly noted with the rapid correction of severe hyponatremia [ 3 ] but infrequently reported from other scenarios of rapid changes of plasma osmolality [ 4 ]. Other medical conditions such as liver disease, hypokalemia, hypophosphatemia, hypoglycemia, and folate deficiency are associated with ODS [ 3 ].…”