Ketoacidosis in the diabetic neurosurgical patient: The steroid conundrum

Introduction: Perioperative administration of steroids is common in patients with brain tumours. However in Diabetic patients steroids are known to rarely induce diabetic ketoacidosis. Case Summary: A 59 year old lady with Type-2 Diabetes Mellitus presented in the evening to the emergency with headache, dizziness, generalised fatigue and vomiting. The patient had mild confusion with GCS 14/15 but neurologically intact. Her serum glucose was 8.3 mmol/l. Emergency head CT revealed left fronto-parietal lesion with peritumoral edema and midline shift. She received stat dose of 12 milligrams dexamethasone and began phenytoin 100 milligrams 8^th hourly. Later the patient vomited and dropped GCS to 11/15. She was intubated, sedated and shifted to surgical intensive care and continued on dexamethasone 6 milligram 6^th hourly. Urgent craniotomy was done next morning. Intraoperatively her serum glucose was 20.5 mmol/l and ABG showed high anion gap metabolic acidosis. Her serum B-hydroxy butyrate was 2.2 mmol/l. She was managed as a case of diabetic ketoacidosis. Conclusion: Preoperative steroid use may possibly trigger diabetic ketoacidosis in the neurosurgical patients. Possible changes in practice for such scenarios would include a judicious approach to steroid usage in such patients and active management of diabetic ketoacidosis in any emergency diabetic patient.