Background: Treating life-threatening diabetic ketoacidosis (DKA) with a pH of <6.9 is extremely challenging and often refractory to treatment using standard fixed dose insulin DKA management protocols which may not work effectively at this low pH because of increased insulin resistance. I.v. bicarbonate (HCO3) use in this situation can be considered but remains controversial due to the risk of significant side effects as well as limited evidence in literature. Here we attempt to describe a case of fulminant DKA without renal failure, where treatment with haemofiltration (HF) for severe metabolic acidosis was successful.
Case history: A 23-year-old female with history of recurrent episodes of DKA and poor diabetes control secondary to non-compliance, presented to the emergency department via ambulance after being found collapsed and had successful cardiopulmonary resuscitation for pulseless electrical activity and was subsequently treated with standard DKA protocol.
Investigations on admission: pH 6.752, HCO3 1.3, lactate 3.1, base excess −30, blood glucose 45 mmol/l, blood ketones 6 mmol/l, creatinine 133 mmol, urea 10.8 mmol, and eGFR 43.
Treatment: Despite maximal DKA treatment over three hours, including 5 l of i.v. fluid, and maximum fixed rate i.v. insulin at 15 units/h, she continued to be in severe metabolic acidosis with pH 6.772, HCO3 1.7, ketones 5, and blood glucose 40.1, without any improvement in her Glasgow coma scale of 8. Options were discussed at length with critical care and endocrine teams regarding use of i.v. bicarbonate therapy vs HF. She was then put on HF which resolved the metabolic acidosis completely within 12 h.
Discussion: Our patient responded to HF with resolution of severe metabolic acidosis. There are no guidelines at present that compare either bicarbonate therapy vs HF for such patients, but HF may be considered as a potentially safe and viable option to correct persistent metabolic acidosis in refractory fulminant DKA.