title: Profound hypokalemia in diabetic ketoacidosis: a therapeutic challenge.
abstract: OBJECTIVE
  To describe profound hypokalemia in a comatose patient with diabetic ketoacidosis.
  
  
  METHODS
  We present a case report, review the mechanisms for the occurrence of hypokalemia in diabetic ketoacidosis, and discuss its management in the setting of hyperglycemia and hyperosmolality.
  
  
  RESULTS
  A 22-year-old woman with a history of type 1 diabetes mellitus was admitted in a comatose state. Laboratory tests revealed a blood glucose level of 747 mg/dL, serum potassium of 1.9 mEq/L, pH of 6.8, and calculated effective serum osmolality of 320 mOsm/kg. She was intubated and resuscitated with intravenously administered fluids. Intravenous administration of vasopressors was necessary for stabilization of the blood pressure. Intravenous infusion of insulin was initiated to control the hyperglycemia, and repletion of total body potassium stores was undertaken. A total of 660 mEq of potassium was administered intravenously during the first 12.5 hours. Despite such aggressive initial repletion of potassium, the patient required 40 to 80 mEq of potassium daily for the next 8 days to increase the serum potassium concentration to normal.
  
  
  CONCLUSIONS
  Profound hypokalemia, an uncommon initial manifestation in patients with diabetic ketoacidosis, is indicative of severe total body potassium deficiency. Under such circumstances, aggressive potassium repletion in a comatose patient must be undertaken during correction of other metabolic abnormalities, including hyperglycemia and hyperosmolality. Intravenously administered insulin should be withheld until the serum potassium concentration is (3)3.3 mEq/L.
authors.affiliation: Division of Nephrology, Lahey Clinic, Burlington, Massachusetts 01850, USA.
authors.forename: Kalyani
authors.initials: K
authors.lastname: Murthy
authors.forename: John T
authors.initials: JT
authors.lastname: Harrington
authors.forename: Richard D
authors.initials: RD
authors.lastname: Siegel
mesh_terms: D000328:Adult; D001786:Blood Glucose / Q000032:analysis; D001794:Blood Pressure / Q000187:drug effects; D003922:Diabetes Mellitus, Type 1 / Q000097:blood / Q000150:complications* / Q000503:physiopathology; D003926:Diabetic Coma / Q000150:complications / Q000188:drug therapy / Q000503:physiopathology; D016883:Diabetic Ketoacidosis / Q000150:complications / Q000175:diagnosis / Q000188:drug therapy*; D004305:Dose-Response Relationship, Drug; D005260:Female; D006801:Humans; D006943:Hyperglycemia / Q000150:complications / Q000188:drug therapy / Q000503:physiopathology; D007008:Hypokalemia / Q000150:complications / Q000175:diagnosis / Q000188:drug therapy*; D007262:Infusions, Intravenous; D007328:Insulin / Q000008:administration & dosage / Q000627:therapeutic use; D009994:Osmolar Concentration; D011188:Potassium / Q000008:administration & dosage / Q000097:blood / Q000627:therapeutic use*; D014662:Vasoconstrictor Agents / Q000008:administration & dosage / Q000494:pharmacology / Q000627:therapeutic use
chemical_list: D001786:Blood Glucose; D007328:Insulin; D014662:Vasoconstrictor Agents; D011188:Potassium