Therapeutic Challenges in Management of Severe Acidosis and Profound Hypokalemia in Pediatric Diabetic Ketoacidosis

Profound hypokalemia in the presence of diabetic ketoacidosis (DKA) is life-threatening condition predisposing patients to cardiac arrhythmias and potentially death. Rarely do patients present with profound hypokalemia (serum K(+) level <2.5 mEq/L). Pediatric patients who present to the hospital with new-onset DKA with no past medical history and have profound severe hypokalemia and acidosis can be very difficult to manage. Given insulin to these patients immediately can lead to further decrease in extracellular potassium level and lead to cardiac dysrhythmias and death. We present the case of a 14-year-old female with new-onset DKA with pH of 6.66, and potassium of 1.6 mEq/L. We started her on careful potassium replacement before starting her on insulin. She had a great prognosis without any complications. Our case presents the lowest level of pH ever reported in a survived pediatric DKA patient. We emphasize the importance of careful management of hypokalemia in patients with severe depletion. Potassium therapy with careful fluid management must be initiated prior to insulin therapy to prevent cardiac completions from hypokalemia.