Endocrine Abstracts

Introduction: Diabetes Ketoacidosis, DKA, is a serious condition with significant morbidity and mortality. Most DKA patients are potassium deficient, but present with hyperkalaemia due to severe acidosis and insulin deficiency. Hypokalaemia at presentation of DKA is extremely uncommon.

Clinical case: A 25 year old man was admitted with severe DKA as a first presentation of diabetes. His venous pH was 6.97, bicarbonate 3.0 mmol/l, potassium 3.4 mmol/l. He was treated with intravenous fluids supplemented with potassium chloride (10 mmol/h), a fixed rate insulin infusion (10 Units/h) and oral potassium supplements. Over the next 8 h, his acidosis failed to improve (serum bicarbonate 2 mmol/l). Despite full replacement, his serum potassium levels dropped to 1.7 mmol/l and he developed new ECG changes, with profound ST depression and QT prolongation to 504 ms. The patient was transferred to the Intensive Care Unit and commenced on 20 mmol/h intravenous potassium chloride. Given the life-threatening ECG changes, insulin was omitted for the next 8 hours until serum potassium level was above 3 mmol/l. Thereafter, insulin treatment was recommenced and the patient required a consistent potassium replacement at a rate of 60 mmol/h to ensure serum potassium ≥4 mmol for 48 hours. This was delivered under cardiac monitoring via central vein. He developed transient polyuria with high potassium urinary losses. His condition gradually improved and after 3 days he made a full recovery.

Summary: We present a case of life-threatening hypokalaemia during management of severe DKA which required a delay in insulin treatment for 8 hours. Insulin therapy causes an intracellular shift in potassium which worsens hypokalaemia. In severe, refractory cases, it may be necessary to withhold insulin therapy until hypokalaemia is corrected. Intensive management is crucial, as hypokalaemia remains the main contributor to DKA associated mortality.