How Low Can You Go? Severe Acidemia in a Patient with Type 2 Diabetes and Diabetic Ketoacidosis

Abstract

Introduction: Type 2 diabetes mellitus (T2DM) is a common disease encountered in the emergency department. Diabeticketoacidosis (DKA) is a potentially life-threatening metabolic disturbance characterized by hyperglycemia, metabolic acidosis,and ketonemia. Traditionally associated with type 1 diabetes mellitus, DKA is becoming increasingly common in type 2 diabetics.Case Report: We present an extreme case of a 66-year-old female with known type 2 diabetes mellitus who presented withaltered mental status and severe metabolic ketoacidosis with a pH of 6.55 and blood glucose of 963 mg/dL. The patient rapidlydecompensated in the emergency department, requiring emergent intubation and central venous access. Fluid resuscitationwas applied, and the patient was started on an insulin infusion. Her blood pressure was supported with dual vasopressortherapy, and she was transferred to the medical intensive care unit. She recovered rapidly and was discharged from the hospital5 days later with no neurologic deficits.Conclusion: This case is notable for the patient’s extreme acidemia, one of the lowest recorded in the literature for a type 2diabetic who survived and was discharged from the hospital. It highlights the importance of early, aggressive treatment of DKAin the emergency department coupled with continued critical care management in the intensive care unit.