The Silent Potassium Avalanche: Unchecking Preoperative Hypokalemia Leading to Perioperative Cardiac Arrest in an Insulin-Treated Diabetic Patient Undergoing a Whipple Procedure: A Case Report

Background: Pancreaticoduodenectomy(Whipple procedure) isa highly complex abdominal surgical procedure, and while perioperative cardiac arrest is infrequent, it is associated with significant morbidity. The established risk factors for postoperative cardiac arrest includehypovolemia, acidosis, and electrolyte imbalances. Case presentation: We present the case of a 67-year-old female with a history of type 1 diabetes mellitus and hypertension who underwent a Whipple procedure under general anesthesia. Preoperative serum potassium levels, which were measured three days prior, were within normal limits (5.28 mmol/L). However, profound hypokalemia (2.71 mmol/L) was detected before the skin incision, and the anesthesiologisttreated the patient with 2 g (26.8 mEq) of intravenous potassium chloride under cardiac output monitoring. The posttreatment serum potassium level at 16:41 was 3.28 mmol/L, indicating persistent hypokalemia. Following the procedure, the patient's vital signs stabilized, meeting the criteria for transfer to the general ward. However, within 30 minutes of ward arrival, the patient experienced a sudden episode of hypertension and tachycardia, rapidly progressing to pulseless electrical activity (PEA) cardiac arrest. Immediate resuscitation efforts, including continuous cardiopulmonary resuscitation (CPR) and epinephrine administration, were initiated. After spontaneous circulation returned, the patient was transferred to the intensive care unit (ICU) and subsequently diagnosed with hypoxic-ischemicencephalopathy (HIE), multiple organ dysfunction syndrome (MODS), or sepsis. Ultimately, the patient succumbed to these complications on day 14 of ICU admission. Conclusions: This critical event underscores the vital importance of meticulous perioperative potassium management in diabetic patients undergoing major abdominal surgery. We advocate for mandatory reevaluation of electrolyte levels within 24 hours preoperatively, particularly following bowel preparation and dietary restriction, in conjunction with prophylactic potassium supplementation and careful insulin administration, as crucial measures to prevent such devastating outcomes.