Early potassium assessment and replacement during emergency department treatment of diabetic ketoacidosis: a systematic review

Background: Diabetic ketoacidosis (DKA) causes metabolic and electrolyte disturbances. Although total-body potassium is depleted, serum potassium at presentation appears normal or even elevated because of transcellular shifts, which create a risk of underestimating impending hypokalemia during treatment. Objective: we aimed to synthesize the available studies on early potassium assessment and replacement during ED and ICU management of DKA. Methods: A systematic review was conducted according to PRISMA 2020. We searched PubMed, Embase, Scopus, Web of Science, and CENTRAL from inception to 2026. Eligible studies included patients with DKA receiving early potassium assessment and replacement during ED or ICU management. Randomized, prospective, and retrospective original studies were included. Qualitative synthesis was performed. Results: Eleven studies published between 1972 and 2025 were included. Hypokalemia at presentation was uncommon, with reported prevalence of 1.3% to 5.6% in adult cohorts. Potassium measurement methods impact clinical interpretation, and pH-adjusted potassium reflects physiological risk rather than unadjusted values. Early protocolized supplementation was associated with more stable potassium levels and better clinical outcomes. Conclusions: In DKA, the principal potassium-related danger is hypokalemia developing after treatment begins. Early assessment, frequent monitoring, and quick replacement are essential, and stronger comparative studies are needed to define replacement strategies.