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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 31, No 6, November/December 2020
AFRICA
339
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
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 diabet-
ic ketoacidosis. The patient developed sudden cardiac arrest
following continuous insulin administration. Laboratory data
revealed severe hypokalaemia. Cardiopulmonary resuscita-
tion was performed immediately for 63 minutes. Although
his spontaneous circulation resumed, the haemodynam-
ics remained unstable. Peripheral extracorporeal membrane
oxygenation was therefore employed for mechanical circu-
latory 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 bilat-
eral 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
Submitted 3/12/19, accepted 16/6/20
Published online 6/7/20
Cardiovasc J Afr
2020;
31
: 339–342
www.cvja.co.zaDOI: 10.5830/CVJA-2020-018
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)
Division of Cardiovascular Surgery, Department of
Surgery, Tri-Service General Hospital, National Defense
Medical Center, Taipei, Taiwan
Ying-Hsiang Wang, MD
Chien-Sung Tsai, MD
Yi-Ting Tsai, MD
Chih-Yuan Lin, MD
Hsiang-Yu Yang
Po-Shun Hsu, MD,
hsuposhun@gmail.comDepartment of Anaesthesia, Tri-Service General Hospital,
National Defense Medical Center, Taipei, Taiwan
Jia-Lin Chen, MD