American Journal of Emergency Medicine (2012) 30, 1311

Correspondence

What the guidelines are sometimes slow to highlight

To the Editor,

The documentation of the prevalence of hypokalemia in unselected patients with Diabetic ketoacidosis such as the ones presenting in the emergency department (ED) [1] represents an important milestone in compiling an evidence base for rationalizing the initial management of DKA. What is truly remarkable is the tardiness of the medical community in responding to the implication that administration of insulin without prior knowledge of potassium status might be hazardous, given the fact that, as far back as 1971, it was recognized that as many as 4% of patients with DKA might have serum Potassium levels amounting to less than 3.5 mEq/L [2]. Even in 1982, it seemed to be a novelty to suggest that “insulin should not be given before this [serum potassium] result is available as the combination of insulin and rehydration may precipitate hypokalemia in initially normokalemic patients….” [3], and I was prevailed upon by senior colleagues to qualify the “rider” I had proposed that my suggestion should apply even if it meant waiting 2 hours for a serum potassium result. The caveat that I added, under pressure, read “Discussing with colleagues here …I agree that two hours is too long to wait for a potassium result before commencing insulin….Because the vast majority of diabetics with ketoacidosis will have levels of serum potassium verging on hyperkalaemia…..” [4].

It was only in the year 2001 that a consensus statement emerged from the American Diabetes Association recom-

mending “insulin treatment should be delayed until potas- sium concentration is restored to N 3.3 mEq/L….” [5]. That was a belated recognition of the reality that injudicious administration of insulin may pose a danger to some patients, and it serves as a reminder that it sometimes takes time for a consensus to emerge on what the best strategy might be to mitigate the risk of harm to patients.

Oscar M.P. Jolobe MB, ChB, D.Phil

Manchester Medical Society c/o John Rylands University Library

M13 9PP Manchester United Kingdom

E-mail address: [email protected] doi:10.1016/j.ajem.2012.05.004

References

1. Arora S, Cheng D, Wyler B, Menchine M. Prevalence of hypokalemia in ED patients with diabetic ketoacidosis. Am J Emerg Med 2012;30: 481-4.
2. Beigelman PM. Severe diabetic ketoacidosis (diabetic coma): 482 episodes in 257 patients: experience of three years. Diabetes 1971;20: 490-500.
3. Jolobe OMP. ABC of diabetes: diabetic emergencies (letter). BMJ 1982;285:509.
4. Jolobe OMP. ABC of diabetes: diabetic emergencies (letter). BMJ 1982;285:810.
5. Kitabchi AE, Umpierez GE, Murphy MB, et al. Hyperglycemic crises in patients with diabetes mellitus. Diabetes Care 2001;24:154-61.

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