The Value of Electrocardiogram Monitoring in Diabetic Ketoacidosis

Abstract

Electrolyte abnormalities cause fatal cardiac arrhythmias in patients with diabetic ketoacidosis. A patient is reported with electrocardiogram (ECG) abnormalities characteristic of toxic hyperkalemia and hypocalcemia. The ECG abnormalities were noted during the first hour after arriving at the hospital. The laboratory values confirming the electrolyte abnormalities were not available for more than 1 h after the ECG indicated the danger of myocardial toxicity. During the initial 2 h of therapy the patient was urinating and not in shock. ECG monitoring of this patient prevented the routine administration of intravenous potassium, which was potentially lethal. The clinical importance of electrolyte levels in the management of diabetic ketoacidosis is the prevention of cardiac arrhythmias. ECG monitoring should be a minimal standard in the management of diabetic ketoacidosis.

Management of Diabetic Ketoacidosis

“…Continuous noninvasive capnography to measure endtidal CO 2 is suggested to correlate well with the degree of acidosis in DKA; the resolution of ketoacidosis is evident in form of steady increment of ETCO 2 towards normal range (35)(36)(37)(38)(39)(40)(41)(42)(43)(44)(45) [56].…”

“…During administration of potassium, adequate urine out put is ensured and potassium and ECG monitored frequently (Table 2), in order to avoid both hyperkalemia (>5.5 mEq/L) and hypokalemia (<3.5 mEql/L) [45]. Recheck K + every 1-2 h if values are outside normal range.…”

Diabetic Ketoacidosis

“…If laboratory measurement of serum potassium is delayed an ECG should be performed for baseline evaluation of potassium status [94,95]. An increased WBC count is response to stress is characteristic of DKA and is not indicative of infection.…”

“…Recommendations for laboratory monitoring include; hourly vital signs and neurologic checks; hourly blood glucose levels for the first 4-6 hours and then to continue with 2 hour intervals in the following period; venous blood gases every 2 hours for 6 hours, then every 4 hours, Na, K and ionized calcium every 2 hours for 6 hours then every 4 hours; magnesium and phosphorus every 4 hours; blood urea nitrogen and creatinine levels (every 4 hours) should also be monitored until stable; basic metabolic profile at admission and then every morning. Fluid intake and urinary output should be monitored [193][194][195]. These are the minimum requirements and should be revised for special situations.…”

“…These are the minimum requirements and should be revised for special situations. For example, patients with initially low potassium, more frequent (hourly) K measurements should be made with ECG monitoring [194,195] or if patient's neurological status is unstable and has a high risk of cerebral edema, more frequent neurologic and vital sign checks (20-30 minutes) should be made [192].…”