Abstract
Objectives
Hypokalemia, a frequently cited complication of diabetic ketoacidosis (DKA) treatment,
can have critical implications, including arrhythmias and death. We assessed the prevalence
of hypokalemia and its associated factors in patients with DKA at our tertiary-care
centre and identified opportunities to improve care.
Methods
We conducted a retrospective chart review to establish the prevalence of hypokalemia
in patients diagnosed with DKA between July 2012 and July 2013. A focused root-cause
analysis was subsequently performed to identify Canadian Diabetes Association DKA
clinical practice guideline deviations and preventable errors that resulted in significant
hypokalemia (K<3.3 mmol/L) during the first 48 hours of management. Clinical and management
details were reviewed to determine the type, preventability and root cause(s) of each
error.
Results
We identified 40 cases of DKA during the study period. The overall prevalence of hypokalemia
during DKA treatment was 38% (15/40), with 25% in type 1 and 56% in type 2 diabetes.
Males were more likely to experience hypokalemia (87%), and 47% of hypokalemic incidents
occurred in the first presentation of diabetes. All 10 cases of significant hypokalemia
were reviewed. We identified 23 errors in 6 (60%) cases, of which 87% were deemed
to be preventable. The most common errors were noncessation of insulin infusion during
hypokalemia (60%), inadequate potassium supplementation (50%) and infrequent biochemical
monitoring (50%).
Conclusions
Hypokalemia occurs frequently during acute DKA management and is often preventable.
Our findings suggest that interventions targeted at enhancing awareness of guidelines
may reduce hypokalemia rates.
Résumé
Objectifs
L'hypokaliémie, une complication qui est fréquemment rapportée lors du traitement
de l'acidocétose diabétique (ACD), peut avoir des conséquences cruciales, dont les
arythmies et la mort. Nous avons évalué la prévalence de l'hypokaliémie et ses facteurs
associés chez les patients souffrant d'ACD de notre centre de soins tertiaires et
défini les possibilités d'amélioration des soins.
Méthodes
Nous avons mené une revue rétrospective de dossiers pour établir la prévalence de
l'hypokaliémie chez les patients ayant reçu un diagnostic d'ACD entre juillet 2012
et juillet 2013. Nous avons subséquemment réalisé une analyse centrée sur les causes
fondamentales pour déterminer les écarts et les erreurs évitables des lignes directrices
de pratique clinique sur l'ACD de l'Association canadienne du diabète qui entraînaient
une hypokaliémie importante (K<3,3 mmol/l) durant les 48 premières heures de la prise
en charge. Nous avons passé en revue les données cliniques et de prise en charge pour
déterminer le type, l'aspect évitable, et la ou les causes fondamentales de chacune
des erreurs.
Résultats
Nous avons relevé 40 cas d'ACD durant la période de l'étude. La prévalence globale
de l'hypokaliémie au cours du traitement de l'ACD était de 38% (15/40), soit 25% du
diabète de type 1 et 56% du diabète de type 2. Les hommes étaient plus susceptibles
d'avoir une hypokaliémie (87%), puis 47% des épisodes hypokaliémiques sont apparus
au premier tableau clinique du diabète. Nous avons passé en revue les 10 cas d'hypokaliémie
importante. Nous avons trouvé 23 erreurs dans 6 (60%) cas et avons considéré que 87%
de ces dernières étaient évitables. Les erreurs les plus fréquentes étaient le maintien
de la perfusion d'insuline au cours de l'hypokaliémie (60%), l'apport supplémentaire
inadéquat en potassium (50%) et la surveillance biochimique peu fréquente (50%).
Conclusions
L'hypokaliémie qui apparaît fréquemment au cours de la prise en charge de l'ACD en
phase aiguë est souvent évitable. Nos résultats suggèrent que les interventions visant
à améliorer la connaissance des lignes directrices peuvent réduire les taux d'hypokaliémie.
Keywords
Mots clés
To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to Canadian Journal of DiabetesAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
- Potassium in severe diabetic ketoacidosis (editorial).Am J Med. 1973; 54: 419-420
- Hypokalemia-induced respiratory failure complicating treatment of diabetic ketoacidosis.J Diabetes Complications. 1994; 8: 55-56
- Hypokalemia and refractory asystole complicating diabetic acidosis, lesions for prevention.BMJ Case Rep. 2012;
- Hospital management of diabetic ketoacidosis: Are clinical guidelines implemented effectively?.Diabet Med. 1997; 14: 482-486
- Incidence and outcomes of hyperglycemic crises: A 5- year study in a tertiary care center in Thailand.J Med Assoc Thai. 2002; 95: 995-1002
- Impact of a critical pathway on inpatient management of diabetic ketoacidosis.Diabetes Res Clin Pract. 2003; 62: 23-32
- Management of diabetic ketoacidosis in a teaching hospital.Acta Diabetol. 2006; 43: 127-130
- Does an integrated care pathway enhance the management of diabetic ketoacidosis?.Diabet Med. 2007; 24: 359-363
- Hypokalemia during treatment of diabetic ketoacidosis: Clinical evidence for an aldosterone-like action of insulin.J Paediatr. 2013; 163: 207-212
- Impact of a hyperglycemic crises protocol.Endocr Pract. 2013; 19: 953-962
- The implementation and evaluation of an evidence-based protocol to treat diabetic ketoacidosis: A quality improvement study.Adv Emerg Nurs J. 2014; 36: 189-198
- Canadian Diabetes Association 2013 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada: Hyperglycemic emergencies in adults.Can J Diabetes. 2013; 37: S72-6
- Prevalence of hypokalemia in ED pts with diabetic ketoacidosis.Am J Emerg Med. 2012; 30: 481-484
- Prevalence of diabetes ketoacidosis rises and still no strict treatment adherence.Curr Diabetes Rev. 2013; 9: 54-61
- Male predominance in ketosis-prone diabetes mellitus.Biomed Rep. 2015; 3: 439-442
- Sample diabetes ketoacidosis clinical order set.(Accessed January 10, 2014)
- Impact of a multidisciplinary approach to guideline implementation in diabetic ketoacidosis.Am J Med Qual. 2008; 23: 47-55
- Mandatory protocol for treating adult patients with diabetic ketoacidosis decreases intensive care unit and hospital lengths of stay: Results of a nonrandomized trial.Crit Care Med. 2007; 35: 41-46
Article info
Publication history
Published online: March 09, 2016
Accepted:
October 9,
2015
Received in revised form:
September 9,
2015
Received:
February 17,
2015
Identification
Copyright
© 2015 Canadian Diabetes Association.
