Abstract

Background: Diabetic ketoacidosis is a common and potentially life-threatening endocrine emergency. Due to broad recognition and protocolised treatment regimes, the mortality rate remains at <1%. Markers of serious disease include hypokalaemia, severe acidosis, reduced Glasgow Coma Scale and uraemia. Patient: We describe the case of a 40-year-old gentleman presenting with acidosis, ketosis, hyperglycaemia and a potassium level below the recordable reference range of our assay. Due to a severe acidosis, an acute kidney injury, severe hypotension and anuria, treatment with the DKA protocol was initiated. In addition to fluid resuscitation the patient received a stat dose of 6 units intravenous insulin and was commenced on a weight based infusion. Multiple arterial blood gas samples did not provide a numerical value for the potassium level, and the patient was treated with IV fluids for over 2 hours before a serum sample confirmed profound hypokalaemia. The patient developed ventricular fibrillation shortly after and died despite advanced cardiac life support, intubation, magnesium replacement and aggressive potassium replacement. Discussion: Hypokalaemia is an uncommon presentation in DKA and is present in only 5% of cases presenting to Emergency Departments (ED). Despite this, its presence is a poor prognostic indicator as the hypokalaemia is worsened by the administration of insulin. It is essential that potassium levels be ascertained prior to the administration of insulin.