Article, Emergency Medicine

Managing combined critical hypothermia, diabetic ketoacidosis and cocaine intoxication noninvasively

Unlabelled imageCase Report

Contents lists available at ScienceDirect

American Journal of Emergency Medicine

journal homepage: locate/ ajem

Managing combined critical hypothermia, diabetic ketoacidosis and cocaine intoxication noninvasively?

Abstract

severe hypothermia with a core temperature below 28?C is critical especially in patients with Diabetic ketoacidosis and carries a high risk of mortality. Our case of a 52-year-old woman presenting with DKA, pH of 6.9, potassium of 7.6 mEq/L, and body temperature of 26?C demonstrates that conservative management can be safe and successful. We used an established cardiac arrest rewarming phase protocol modified to active warming with the Meditherm 3 Machine and the facility-used rigorous DKA protocol to successfully and safely achieve rewarming without hemodialysis or extracorporeal maneuvers. Our patient arrived even more hypothermic than all previously described cases and regained normothermia and an equalized acid-base and electrolyte balance within 12 hours after admission. Eventually, no new neurologic deficit was present on discharge.

Severe hypothermia (SH) is defined as a core temperature below 28?C (82?F) [1] and can be associated with diabetic ketoacidosis (DKA) [2]. Diabetic ketoacidosis is an acute, life-threatening compli- cation of diabetes mellitus type 1, characterized by the triad of hyperglycemia, Anion gap metabolic acidosis, and ketonemia, caused by insulin insufficiency. Cocaine abuse has been associated with recurrent DKA [3,4].

We present the case of a 52-year-old type 1 Diabetic woman, who was found unresponsive in her basement in June. Her temperature on admission was 26.3?C (79.3?F). Heart rate was 38 per minute; respiratory rate, 12 per minute; and O2 saturation on 4 L nasal cannula was 88%. Laboratory studies revealed a pH of 6.90, pCO2 of 17 mm Hg, pO2 of 187 mm Hg, and bicarbonate of 4 mEq/L, with a Serum glucose of 1080 mg/dL, B-hydroxybutyrate of 12.46 mmol/L, potassium of 7.6 mEq/L, sodium of 124 mEq/L, anion gap of 25, creatinine of 2.8 mg/dL, and serum osmolality of 368 mOsm/kg H2O. Drug screen was positive for cocaine and marihuana. On physical examination, pupils were fixed and dilated, and the patient was only minimally responsive.

She was intubated for airway protection, started on dopamine for cardioCirculatory support, and treated with the facility-used DKA protocol. The emergency department initiated rewarming with conservative measures including warmed intravenous fluids, warmed ventilator air, and blankets, which were only minimally effective. After transfer to the medical intensive care unit, we started the “rewarming phase” of the protocol for therapeutic

? There was no support in the form of equipment, drugs, or grants needed to draft this abstract.

hypothermia, which is established in our facility and frequently used after cardiac arrest. Therefore, the patient was wrapped with the Gaymar torso vests and leg wraps, connected to a Meditherm

3 (Gaymar Hyper/Hypothermia Machine; Gaymar Industries, Inc, New York, NY, USA); intravenous fluids were warmed to 42?C; and electrolyte disturbances were normalized. With these mea- sures, her core temperature, measured with a bladder thermom- eter probe, rose approximately 2?C per hour. Within the first 15 minutes, she was rewarming at 0.5?C, which accelerated to warming 26.8?C to 29.6?C within the first hour. At the 3-hour mark, temperature reached 32?C, and aggressive rewarming was stopped. Body temperature normalized 10 hours after admission. No shivering, seizures, or cardiac arrhythmias occurred. Pressor support could be discontinued 5 hours into the rewarming process, and she remained hemodynamically stable. Anion gap closed after 12 hours on the DKA protocol, and glucose, electrolyte, and acid- base disturbances as well as kidney function normalized accord- ingly. She was extubated 16 hours after intubation and immedi- ately able to lead a conversation. Unfortunately, she became agitated from withdrawl, which was treated successfully with antipsychotic medications. Eventually, she regained her neurologic baseline and was able to be discharged home without new neurologic deficits.

To our knowledge, this is the first report of a case with SH (26.3?C) treated successfully with Noninvasive measures using the Gaymar Hyper/Hypothermia machine with great recovery even with the presence of severe DKA (pH 6.9) and cocaine toxicity.

Current recommendations for management of SH are vague and vary from external to invasive internal warming strategies including venovenous rewarming, hemodialysis, continuous arteriovenous rewarming, and cardiopulmonary bypass [5,6]. Mortality of hypo- thermia in DKA has been reported up to 61% in a retrospective observational study where 13 patients with a mean core temper- atures of 29.7?C were treated with conservative measures [2]. Two cases of DKA and hypothermia in the setting of alcohol intoxication treated with conservative measures and a benign outcome have recently been published. In these cases, core temperature (29?C and 32?C) was by far not as critical as in our patient [7]. Rapid rewarming is crucial especially in DKA patients because insulin is ineffective at temperatures below 30?C. Lin et al [8] reported a case of DKA with 29?C and hemodynamic instability that was success- fully treated with venoarterial extracorporeal circulation for 20 hours. Internal warming techniques such as pleural lavage or hemodialysis are also used [9,10] but have not yet been published under the special circumstances of DKA. Hemodialysis can rewarm at a reported rate of 1.9?C an hour intermittently but carries the risk of a catheter insertion and hypotension. We achieved similar rates

0735-6757/$ – see front matter (C) 2014

of rewarming as reported with hemodialysis, with much less delay and no risk of catheter insertion.

Our case demonstrates that aggressive conservative manage- ment with utilization of an established rewarming phase protocol (developed for therapeutic hypothermia) including active warming with the Meditherm 3 is not only safe and successful in patients with hypothermia combined with DKA but also superior to elsewhere described techniques. Our patient was even more hypothermic than all previously described cases, and we were still able to sufficiently increase core temperature to optimize insulin action and wean off pressors without using invasive and potentially harmful procedures within the critical first 3-hour window.

In summary we conclude that aggressive, controlled rewarming using the rewarming phase of a therapeutic hypothermia protocol and the Meditherm 3 can safely be used in severely hypothermic patients with DKA.

Miriam Freundt MD Adel Obaji MD Department of Medicine Rochester General Hospital Rochester, NY, USA

E-mail address: [email protected]

John K. Hix MD Department of Medicine Rochester General Hospital Rochester, NY, USA

Nephrology Division Rochester General Hospital

University of Rochester School of Medicine

and Dentistry, Rochester

NY 14621, USA

http://dx.doi.org/10.1016/j.ajem.2013.10.042

References

  1. Jolly BT, Ghezzi KT. accidental hypothermia. Emerg Med Clin North Am 1992;10: 311-27.
  2. Gale EA, Tattersall RB. Hypothermia: a complication of diabetic ketoacidosis. BMJ 1978;2:1387-9.
  3. Warner EA, Greene GS, Buchsbaum MS, et al. Diabetic ketoacidosis associated with cocaine use. Arch Intern Med 1998;158:1799-802.
  4. Nyenwe EA, Loganathan RS, Blum S, et al. Active use of cocaine: an independent risk factor for recurrent diabetic ketoacidosis in a city hospital. Endocr Pract 2007;13:22-9.
  5. Mechem CC, Zafren K. Accidental hypothermia in adults.
  6. Soar J, Perkins GD, Abbas G, et al. European Resuscitation Council Guidelines for Resuscitation 2010 Section 8. Cardiac arrest in special circumstances: electrolyte abnormalities, poisoning, drowning, accidental hypothermia, hyperthermia, asthma, anaphylaxis, cardiac surgery, trauma, pregnancy, electrocution. Resusci- tation 2010;81:1400-33.
  7. Nambu T, Mori K, Shinoto Y, et al. Diabetic ketoacidosis accompanied by hypothermia: a case report. Diabetes Res Clin Pract 2012;96:326-30.
  8. Lin MH, Ko WJ, Shih SR, Wang CH. Venoarterial extracorporeal membrane oxygenation resuscitation in diabetic ketoacidosis with hypothermic cardiocir- culatory instability. The American Journal of Emergency Medicine 2012;30: 259.e255.
  9. Kjaergaard B, Bach P. Warming of patients with accidental hypothermia using warm water pleural lavage. Resuscitation 2006;68:203-7.
  10. Hernandez E, Praga M, Alcazar JM, et al. Hemodialysis for treatment of accidental hypothermia. Nephron 1993;63:214-6.

Leave a Reply

Your email address will not be published. Required fields are marked *