Respiratory Failure in the Course of Treatment of Diabetic Ketoacidosis

Three patients developed acute respiratory failure during treatment of diabetic ketoacidosis (DKA) diagnosed by the combination of hyperglycemia, anion gap metabolic acidosis, and presence of ketone bodies in serum. All three required tracheal intubation and mechanical ventilation. Table 1 shows pertinent laboratory values at admission and immediately before tracheal intubation. Serum anion gap was computed as [Na]S − ([Cl]S + [TCO2]S), where [Na]S, [Cl]S, and [TCO2]S are, respectively, the serum sodium, chloride, and total carbon dioxide concentrations. Serum tonicity in mOsm/l was calculated as 2 × [Na]S + [Glu]S, where [Glu]S is serum glucose concentration in mmol/l. ### Patient 1 A 12-year-old girl with no previous history of diabetes was admitted with DKA, symptomatic hypovolemia, and lethargy. On admission, her serum potassium concentration was in the normal range (Table 1), and her serum phosphate was 6.1 mg/dl. Initial treatment consisted of infusion of insulin and large volumes of saline. After 4 hours, she experienced cardio-respiratory arrest. Electrocardiogram showed ventricular fibrillation. Laboratory values obtained just before the arrest revealed profound hypokalemia and hypercapnia (Table 1). She recovered after electromechanical resuscitation, intubation, and infusion of large amounts of potassium chloride. However, she developed acute kidney injury, which improved without the need for dialysis and required prolonged tracheal intubation (1 week). ### Patient 2 A 14-year-old boy with no history of diabetes was admitted with DKA, coma, seizures, and profound hypotension. Computed tomography did not reveal any brain pathology. Admission laboratory values showed extreme hyperglycemia with hypertonicity and hypokalemia (Table 1). The boy received intravenous insulin plus large volumes of saline containing potassium chloride. After 3 hours, his hypotension had improved, but his serum glucose level was 1,794 mg/dl, serum sodium was 148 mEq/l, serum tonicity was 391.7 mOsm/l, serum chloride …