Amit Mehta, MD
Associate Clinical Professor
Oregon Health & Science University, United States
Disclosure information not submitted.
Matthew Hudkins, MD
Oregon Health and Sciences University
Portland, Oregon
Disclosure information not submitted.
Title: Loss of pacemaker capture and cardiac arrest: a rare complication of diabetic ketoacidosis.
Introduction: Diabetic Ketoacidosis (DKA) is a common admission to the pediatric ICU. Cerebral edema is a severe complication of DKA and there is some evidence of association with administration of sodium bicarbonate. Current consensus guidelines recommend against administration of sodium bicarbonate to correct metabolic acidosis unless there is severe acidosis compromising cardiac contractility or life-threatening hyperkalemia.
Description: An 11 year-old female presented to the emergency department of an academic tertiary care hospital with altered mental status, malaise, and headache. Further history of present illness was significant for polyuria, polydipsia, and fatigue, as well as a past medical/surgical history of complete heart block and pacemaker dependence. Her initial labs were notable for severe metabolic acidosis with a pH of 6.94 and base excess of -30, with a glucose of 475. The diagnosis of new-onset type 1 diabetes with severe DKA was made and she was started on an insulin infusion and transferred to the pediatric ICU. She continued to have hyperglycemia and metabolic acidosis that was refractory to an increase in the dose of her insulin infusion. Several hours after admission she had an abrupt cardiac arrest. Though return of spontaneous circulation was achieved, she developed worsening shock and was being prepared for extracorporeal support when she experienced a second cardiac arrest and underwent cannulation for veno-arterial ECMO while being resuscitated. Review of telemetry at the periods of her cardiac arrest showed intermittent loss of pacemaker capture leading to bradycardia followed by PEA. She had a reassuring neurologic exam following cannulation, but persistent poor cardiac function and renal failure, ultimately going on to receive a heart and kidney transplant at a referral center.
Discussion: In the rare case of a patient with pacemaker dependence who has severe acidosis due to DKA, the risk of loss of pacemaker capture and potential for cardiac arrest should be considered, along with the risk of cerebral edema with bicarbonate administration to more quickly correct the metabolic acidosis.