Case report
Severe acidosis caused by starvation and stress

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Abstract

A 1-year-old boy had severe anoxic brain injury owing to a cardiorespiratory arrest. He had an initial metabolic acidosis, but this largely resolved by hospital day 2. He then had a persistent, profound metabolic acidosis. Evaluation on hospital day 6 found that the patient had ketonemia, ketonuria, and a normal serum glucose level; he had received no intravenous dextrose during his hospitalization. The dextrose-free fluids were given initially to protect his brain from the deleterious effects of hyperglycemia after brain injury. Continuation beyond 24 hours was inadvertent. The initiation of dextrose-containing intravenous fluids produced a rapid resolution of his metabolic acidosis. Starvation usually produces a mild metabolic acidosis, but when combined with physiologic stress, starvation may cause a severe metabolic acidosis. Among the few reports of severe starvation ketoacidosis, our case is unique because the patient was monitored closely in an intensive care unit, allowing us to describe the time course of the acidosis in detail.

Section snippets

Case report

A 1-year-old African-American boy, with a medical history of mild gastroesophageal reflux and mild asthma, was brought to Children’s Hospital of Wisconsin via ambulance after a cardiac arrest. He was in his usual state of good health the morning of admission, but around 2 pm he was discovered unresponsive at daycare. He was not breathing, and no pulse was detected. The daycare worker initiated cardiopulmonary resuscitation. Emergency medical services reestablished a pulse after 30 minutes. On

Discussion

We have described a 1-year-old boy with severe anoxic brain injury who received no glucose or any other nutrition for over 5 days. Dextrose was withheld because of the potential deleterious effects of hyperglycemia after ischemic brain injury. The patient initially had an increased gap metabolic acidosis, probably secondary to lactic acidosis from hypoxia, but this resolved quickly with fluid resuscitation. Beginning on day 2 after admission, the patient had a metabolic acidosis that was

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