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VOLUME 17 NUMBER 1 • JULY 2020
29
SA JOURNAL OF DIABETES & VASCULAR DISEASE
CASE REPORT
Persistent cardiac arrest caused by profound
hypokalaemia after large-dose insulin injection in a
young man with type 1 diabetes mellitus: successful
rescue with extracorporeal membrane oxygenation and
subsequent ventricular assist device
YING-HSIANG WANG, CHIEN-SUNG TSAI, YI-TING TSAI, CHIH-YUAN LIN, HSIANG-YU YANG,
JIA-LIN CHEN, PO-SHUN HSU
Correspondence to: Po-Shun Hsu
Division of Cardiovascular Surgery, Department of Surgery, Tri-Service
General Hospital, National Defense Medical Center, Taipei, Taiwan
e-mail:
hsuposhun@gmail.comYing-Hsiang Wang, Chien-Sung Tsai, Yi-Ting Tsai, Chih-Yuan Lin,
Hsiang-Yu Yang
Division of Cardiovascular Surgery, Department of Surgery, Tri-Service
General Hospital, National Defense Medical Center, Taipei, Taiwan
Jia-Lin Chen
Department of Anaesthesia, Tri-Service General Hospital,
National Defense Medical Center, Taipei, Taiwan
Published online in
Cardiovasc J Afr:
6/7/20
S Afr J Diabetes Vasc Dis
2020;
17
: 29–32
Abstract
A 28-year-old man who had a history of type 1 diabetes
mellitus with poor medication compliance was referred to
the emergency department of our institute with suspected
diabetic ketoacidosis. The patient developed sudden
cardiac arrest following continuous insulin administration.
Laboratory data revealed severe hypokalaemia. Cardio-
pulmonary resuscitation was performed immediately
for 63 minutes. Although his spontaneous circulation
resumed, the haemodynamics remained unstable.
Peripheral extracorporeal membrane oxygenation was
therefore employed for mechanical circulatory support.
Echocardiography under these conditions revealed
generalised hypokinesia of the bilateral ventricles. The left
ventricular ejection fraction was only 10–15%. The chest
film revealed bilateral pulmonary congestion. The patient
developed multiple organ dysfunction, including acute
kidney injury, liver congestion and persistent pulmonary
oedema, although the hypokalaemia resolved. A temporary
bilateral ventricular assist device (Bi-VAD) was used for
superior systemic perfusion and unloading of the bilateral
ventricles after 16 hours of extracorporeal membrane
oxygenation support. After the start of maintenance using
the Bi-VAD, extracorporeal membrane oxygenation was
discontinued and the inotropic agents were tapered down
immediately. Subsequently, the haemodynamics stabilised.
All the visceral organs were well perfused with Bi-VAD
support. Subsequent echocardiography demonstrated
recovery from the myocardial stunning, with the left
ventricular ejection fraction returning to 50–60%. The Bi-VAD
was gradually weaned and successfully removed 12 days
after implantation. The patient had an uneventful recovery
and was discharged without organ injury. Over one year of
follow up in our out-patient clinic, adequate cardiac function
and improved diabetes control were found.
Keywords:
hypokalaemia, cardiac arrest, cardiogenic shock,
ventricular assist device
Profound hypokalaemia (< 2.5 mmol/l), a severe complication
following subcutaneous administration of insulin, is reported in
5–10% of patients with type 1 diabetes mellitus,
1
and can easily
be resolved through potassium infusion. Clinical manifestations
of hypokalaemia vary in severity, depending on the acuteness
and degree of the hypokalaemia. Although mild degrees of
hypokalaemia are usually asymptomatic, severe degrees can
lead to marked muscle weakness, ileus, and lethal arrhythmia,
including cardiac arrest, ventricular tachycardia (VT) and ventricular
fibrillation (Vf). The incidence of Vf has been found to be three- to
five-fold higher in patients with low serum potassium compared
with patients with high serum potassium concentrations.
2,3
Although the mortality rate for hypokalaemia-related VT/ Vf
has not been reported, the mortality rate for cardiogenic shock
following cardiopulmonary resuscitation (CPR) is 50–80%.
4
Herein, we report on a young man who developed refractory
hypokalaemia-induced VT/Vf and cardiogenic shock following CPR.
We performed emergent veno-arterial (VA)-mode extracorporeal
membrane oxygenation (ECMO) in the emergency room; thereafter,
a bilateral ventricular assist device (Bi-VAD) was implanted to
provide cardiogenic shock after CPR.
Case report
A 28-year-old man with a history of type 1 diabetes mellitus and
inadequate compliance with insulin administration was referred
to our emergency department due to general weakness with
impaired consciousness lasting one day. Laboratory data revealed
hyperketonaemia (blood ketone level 7.6 mmol/l), hyperglycaemia