Potassium losses are often greater than sodium losses. While patients are often initially hyperkalemic, hypokalemia commonly occurs after treatment has commenced in diabetic ketoacidosis and is related to absolute losses, hemodilation, the movement of glucose back into the cell, and correction of acidosis. It is the most common reversible cause of death during the management of diabetic ketoacidosis.
As with fluid and insulin requirements, there is no place for inflexibility in the recommended potassium replacement requirements. It is important to measure the serum potassium initially and approximately 1 h after the commencement of insulin in the resuscitation phase. This will give an indication of the trend. There may also be chronic or acute renal impairment, interfering with potassium excretion. The potassium should be measured at least every 2 h in the early stages of resuscitation and then less regularly as the levels achieve a more predictable pattern.
A rate of between 5 and 30 mmol/h of potassium is usually required during resuscitation of diabetic emergencies. Because of the relatively high concentrations, it should be delivered via a large vein or central venous catheter. Continuous ECG monitoring is necessary with such high fluxes of extra- and intracellular potassium levels.
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