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| General teaching points | Comments pertinent to current case |
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| Treatment of one electrolyte or metabolic abnormality can critically worsen another. In a patient with multiple disturbances, a comprehensive management plan must prioritize the most to least life-threatening disturbance and treat accordingly. Additionally, consideration must be made for all possible treatment interactions, particularly when the treatment of a less critical problem can exacerbate a life-threatening condition | (i) Hypokalemia and hypophosphatemia were the two most life-threatening conditions in current patient. Since the treatment of diabetic ketoacidosis (DKA) with insulin with or without glucose support could have exacerbated the severe hypokalemia and precipitate cardiac arrest, such treatment was intentionally delayed. Aggressive potassium replacement with both KCl and KPO4 to achieve a safer serum potassium level was done PRIOR to the treatment of DKA |
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Comprehensive protocol for the management of hyponatremia:
(i) Determine osmotic demyelination risks (ODS) and appropriate rate of correction
(ii) Assess and treat all correctable ODS risks (hypokalemia, hypomagnesemia, hypophosphatemia, altered glucose metabolism, and clinical need for thiamine)
(iii) Understand that potassium can increase serum sodium exactly as if the same amount of sodium is being administered
(iv) Monitor urine output and its content of sodium and potassium for any possible aquaretic phase | (i) While hyponatremia was being corrected with KCl and KPO4 infusions, the immediate plan to monitor and correct factors [hypophosphatemia and hypomagnesemia] associated with high ODS risks led to the prompt recognition of severe and life-threatening hypophosphatemia
(ii) In addition to the correction of concurrent electrolyte disturbances, thiamine supplementation should be considered in patients with malnutrition or alcoholism as thiamine deficiency has been implicated in increasing the risk for ODS
(iii) Current patient’s serum sodium concentration improved as planned with only potassium-containing fluids
(iv) Aggressive monitoring of both urine output and content of effective electrolytes (sodium and potassium) allows for prompt intervention and thus prevention of rapid over correction of hyponatremia |
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| KCl is as effective as NaCl solution as a volume expander and may be preferred or even required when potassium is critically deficient | (i) The substitution of KCl for NaCl solution for volume expansion can only be given in cases of severe hypokalemia. The rate and concentration of the KCl solution MUST be adjusted to assure a safe rate of increase in serum sodium
(ii) Note that a maximum of 20 mEq of KCl may be continuously infused per hour through a central venous catheter |
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| Respiratory hyperventilation and metabolic acidosis associated with diabetic ketoacidosis alone may be easily and promptly reversed with the administration of insulin. Persistent abnormalities should thus prompt an evaluation for other underlying etiologies | (i) Following the administration of insulin, our patient’s respiratory status improved from a respiratory rate up to mid-30’s breaths per minute down to mid-20’s within 24 hours
(ii) Similarly, patient’s serum total CO2 improved from 6 to 14 mEq/L within 8 hours
(iii) Note, however, close monitoring of potassium must be done following insulin and glucose support therapy. With the initiation of insulin therapy, patient’s serum potassium decreased from a high of 3.2 mEq/L to 2.7 mEq/L within 7 hours |
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