Re-visiting pH-adjusted potassium to avoid hypokalemic crisis during management of diabetic ketoacidosis: A conceptual framework |
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Authors: | Atif Usman Mohd Farooq Shaikh Juman Abdulelah Dujaili Norlaila Mustafa Siew Hua Gan |
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Institution: | 1. School of Pharmacy, Monash University Malaysia, Bandar Sunway, Selangor, Malaysia;2. Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, Bandar Sunway, Malaysia;3. Department of Endocrinology, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia |
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Abstract: | Background and aimsDiabetic ketoacidosis (DKA) treatment guidelines recommend to initiate potassium-replacement when serum potassium (SK) drops within normal range, and to withhold insulin if SK is below normal. Despite strict recommendations, hypokalemia is frequently observed in DKA.MethodsScientific literature was thoroughly searched to find 1) DKA treatment guidelines, 2) studies reporting hypokalemia in DKA, 3) and literature elaborating mechanisms involved in hypokalemia.ResultsAcidosis affects SK and its regulators including insulin, catecholamines and aldosterone. Current conceptual framework is an argument to gauge the degree of hypokalemia before it strikes DKA patients utilizing SK level after adjusting it with pH. Suggested approach will reduce hypokalemia risk and its associated complications. The nomogram calculates pH-adjusted potassium and expected potassium loss. It also ranks hypokalemia associated risk, and proposes the potassium-replacement rate over given time period. The differences between current DKA treatment guidelines and proposed strategy are also discussed. Moreover, reasons and risk of hyperkalemia due to early initiation of potassium replacement and remedial actions are debated.ConclusionIn light of proposed strategy, utilizing the nomogram ensures reduced incidence of hypokalemia in DKA resulting in improved clinical and patient outcomes. Pharmacoeconomic benefits can also be expected when avoiding hypokalemia ensures early discharge. |
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Keywords: | Diabetic ketoacidosis Potassium Hypokalemia Cardiovascular outcome Patient outcome Emergency department |
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