A physiologic-based approach to the treatment of a patient with hypokalemia

Maximum serum K+ concentration within 1 hour with enteral replacement in severe hypokalemia

Introduction

Introduction: we report two cases with severe hypokalemia. Patients and methods: a 68-year-old woman was admitted with lower limb swelling and urinary symptoms; on the fourth day serum K+ concentration (s[K+]) was 2.3 mmol/L. A 64-year-old woman was admitted with pain in the lumbosacral spine, she was diagnosed with multiple myeloma. After receiving specific therapy she showed s[K+] at 2.4 mmol/L. A KCl solution containing 26.8 mEq of K+ was administered enterally, which increased s[K+] by 0.7 mmol/L within 1 h. Results and conclusion: these cases reveal that peak s[K+] may be achieved within 1 hour after KCl intake in severe hypokalemia, which is probably faster than IV administration.

Renal toxicity caused by diethylene glycol: an overview

Diethylene glycol (DEG) is nephrotoxic, potentially resulting in high morbidity and mortality. Its main nephrotoxic by-product is diglycolic acid (DGA). This narrative overview summarizes selected literature with a focus on clinical findings, pathophysiology, diagnosis including morphological features of renal biopsies, and management. The kidney injury in DEG poisoning is secondary to proximal tubular necrosis caused by DGA. Marked vacuolization and edema of epithelial cells obstruct the lumen, reducing urine flow and, consequently, resulting in anuria and uremia. The clinical alterations due to DEG poisoning are dose-dependent. Patients may present with gastrointestinal symptoms and anion gap metabolic acidosis, followed by renal failure, and, later, encephalopathy and neuropathy. Although this three-phase pattern has been described, signs and symptoms may be overlapping. Data about DEG intoxication is scarce. Sometimes the diagnosis is challenging. The management includes supportive care, gastric decontamination, correction of acid-base disorders, and hemodialysis. The understanding of the metabolic processes related to DEG poisoning may contribute to its management, preventing death, serious sequels, or irreversible lesions.

Zonisamide-induced distal renal tubular acidosis and critical hypokalaemia

A woman in her 20s presented with rapidly progressive muscle weakness and a 1-month preceding history of fatigability, nausea and vomiting. She was found to have critical hypokalaemia (K+ 1.8 mmol/L), a prolonged corrected QT interval (581 ms) and a normal anion gap metabolic acidosis (pH 7.15) due to zonisamide-induced distal (type 1) renal tubular acidosis. She was admitted to the intensive care unit for potassium replacement and alkali therapy. Clinical and biochemical improvement ensued, and she was discharged after a 27-day inpatient stay.

Development of a Machine-Learning Model for Prediction of Extubation Failure in Patients with Difficult Airways after General Anesthesia of Head, Neck, and Maxillofacial Surgeries

(1) Background: Extubation failure after general anesthesia is significantly associated with morbidity and mortality. The risk of a difficult airway after the general anesthesia of head, neck, and maxillofacial surgeries is significantly higher than that after general surgery, increasing the incidence of extubation failure. This study aimed to develop a multivariable prediction model based on a supervised machine-learning algorithm to predict extubation failure in adult patients after head, neck, and maxillofacial surgeries. (2) Methods: A single-center retrospective study was conducted in adult patients who underwent head, neck, and maxillofacial general anesthesia between July 2015 and July 2022 at the Shanghai Ninth People's Hospital. The primary outcome was extubation failure after general anesthesia. The dataset was divided into training (70%) and final test sets (30%). A five-fold cross-validation was conducted in the training set to reduce bias caused by the randomly divided dataset. Clinical data related to extubation failure were collected and a stepwise logistic regression was performed to screen out the key features. Six machine-learning methods were introduced for modeling, including random forest (RF), k-nearest neighbor (KNN), logistic regression (LOG), support vector machine (SVM), extreme gradient boosting (XGB), and optical gradient boosting machine (GBM). The best performance model in the first cross-validation dataset was further optimized and the final performance was assessed using the final test set. (3) Results: In total, 89,279 patients over seven years were reviewed. Extubation failure occurred in 77 patients. Next, 186 patients with a successful extubation were screened as the control group according to the surgery type for patients with extubation failure. Based on the stepwise regression, seven variables were screened for subsequent analysis. After training, SVM and LOG models showed better prediction ability. In the k-fold dataset, the area under the curve using SVM and LOG were 0.74 (95% confidence interval, 0.55-0.93) and 0.71 (95% confidence interval, 0.59-0.82), respectively, in the k-fold dataset. (4) Conclusion: Applying our machine-learning model to predict extubation failure after general anesthesia in clinical practice might help to reduce morbidity and mortality of patients with difficult airways after head, neck, and maxillofacial surgeries.

Geriatric Pharmacotherapy Case Series: Thiazide-Induced Hypokalemia

Introduction The patient was a 72-year-old man with a history of hypertension, hyperlipidemia, benign prostatic hyperplasia, and oropharyngeal cancer. His home medications include amlodipine, atorvastatin, hydrochlorothiazide, and tamsulosin. He lives alone and eats a soft, bland, nutrient-poor diet. During his annual primary care visit, he is found to have a serum potassium level of 3.3 mEq/L (reference range 3.5-5.0). Assessment The use of hydrochlorothiazide, a thiazide diuretic, as well as his low consumption of dietary potassium, have likely contributed to his mild, asymptomatic hypokalemia. Outcome The patient’s serum potassium normalizes following replenishment with a 10 mEq microencapsulated potassium chloride (KCl) extended release (ER) tablet three times a day with meals for one week. A registered dietitian was consulted to provide recommendations for a well-balanced diet, consistent with his dietary texture needs. Conclusions Hypokalemia is a commonly encountered electrolyte disorder, occurring in about 3 to 4% of community-dwelling elders.1 Though asymptomatic hypokalemia is often an incidental finding, it is associated with an increased risk of major adverse cardiovascular events if left untreated and thus should be promptly corrected when discovered.2

Factors Associated with Congenital Heart Disease in Severely Malnourished Children under Five and Their Outcomes at an Urban Hospital, Bangladesh

Congenital heart disease (CHD) is one of the most common types of birth defect with a high morbidity and mortality, particularly in severely malnourished children under five. In this study, we aim to identify the predicting factors for CHD and their outcomes. 694 malnourished children under five years of age admitted between April 2015 and December 2017 constituted the study population. Of them, 64 were cases of CHD, and by comparison 630 were without CHD. CHD was diagnosed clinically and confirmed by echocardiogram. 64% of the cases had a single defect. Cases were more likely to be present with diarrhea, cough, respiratory distress, cyanosis, hypoxemia, hypoglycemia and hypernatremia on admission. The cases also had a high proportion of severe sepsis, bacteremia, heart failure, respiratory failure and death, compared to those without CHD. Cough (95% CI = 1.09–18.92), respiratory distress (95% CI = 1.46–5.39) and hypoxemia (95% CI = 1.59–6.86) were found to be the independent predictors for CHD after regression analysis, and their early identification might be helpful to lessen ramifications, including mortality, in such populations, especially in resource-limited settings.

Oral Liquid Potassium Chloride Dosing Pathway in a Tertiary Care Veteran Affairs Academic Medical Center

Hypokalemia, defined as a serum potassium (K) concentration of <3.5 mEq/L, is an electrolyte imbalance commonly found in hospitalized patients. Hypokalemia is associated with potentially severe complications, including arrhythmias, which necessitate careful monitoring and repletion with potassium. In the inpatient setting, serum K may be repleted via intravenous or oral routes, with oral administration preferred. Potassium chloride (KCl) for oral administration is widely available in both immediate as well as an extended release formulations. Immediate release liquid KCl is optimal for inpatient use since it demonstrates rapid absorption and subsequent increase in serum K levels. However, acquisition costs for unit dose oral liquid KCl have prompted some institutions to implement guidance for appropriate use of KCl oral liquid. In this article, we describe the creation of a clinical pathway for ordering of oral immediate release KCl for inpatients at a tertiary Veterans Affairs Academic Medical Center.

"I Can't Move My Arms and Legs": A Rare Cause of Hypokalemia-Induced Quadriparesis

Hypokalemia is a relatively common electrolyte abnormality in hospitalized patients. Severe hypokalemia (<2.5 mEq/L) can lead to profound muscle weakness or paralysis, especially in the setting of acute onset of hypokalemia. Multiple mechanisms of hypokalemia have been described, such as decreased potassium intake, increased losses, and increased transcellular shift of potassium. Drugs can rarely cause hypokalemia by one of the above-mentioned mechanisms. Here, we report a case of cocaine use leading to severe hypokalemia manifesting as quadriparesis. The aggressive repletion of potassium led to a complete resolution of muscular weakness.

Early management of hypokalaemia in severely malnourished children under five could help to reduce deaths in developing countries

AIM

This study evaluated the factors associated with hypokalaemia and their outcomes, in severely malnourished children under 5 years of age.

METHODS

We focused on 407 severely malnourished children under five who were admitted to the Dhaka Hospital, International Centre for Diarrhoeal Disease Research, Bangladesh, from April 2011 to June 2012. The cases were 139 with hypokalaemia, and the comparisons were 268 without hypokalaemia.

RESULTS

Cases were older than the comparisons, with a poor socio-economic status and a higher death rate of 12% vs 7%. They were more likely to present with a history of measles, diarrhoea, lethargy, lower pulse rates, hyponatraemia, metabolic acidosis, hypocalcaemia, hypomagnesaemia, higher height or length, severe underweight, severe wasting and leucocytosis on admission. At discharge, cases had lower potassium levels and a higher proportion had persistent hypokalaemia. Cases received longer treatment with ampicillin and micronutrients. After adjusting for confounders, hypokalaemia was independently associated with poor socio-economic status, diarrhoea, lower pulse rates, hypocalcaemia, metabolic acidosis and leucocytosis.

CONCLUSION

Identifying simple clinical signs, like diarrhoea and lower pulse rates, and laboratory parameters, such as hypocalcaemia and metabolic acidosis, may enable the early management of hypokalaemia in severely malnourished children under 5 years. This could reduce morbidity and mortality.

Primary aldosteronism is associated with risk of urinary bladder stones in a nationwide cohort study

We analyzed database from the Taiwan National Health Insurance to investigate whether primary aldosteronism (PA) increases the risk of bladder stones. This retrospective nationwide population-based cohort study during the period of 1998–2011 compared patients with and without PA extracted by propensity score matching. Cox proportional hazard models and competing death risk model were used to estimate the hazard ratios (HRs), sub-hazard ratios (SHRs) and corresponding 95% confidence intervals (CIs). There were 3442 patients with PA and 3442 patients without PA. The incidence rate of bladder stones was 5.36 and 3.76 per 1000 person-years for both groups, respectively. In adjusted Cox hazard proportional regression models, the HR of bladder stones was 1.68 (95% CI 1.20–2.34) for patients with PA compared to individuals without PA. Considering the competing risk of death, the SHR of bladder stones still indicates a higher risk for PA than a comparison cohort (SHR, 1.79; 95% CI 1.30–2.44). PA, age, sex, and fracture number were the variables significantly contributing to the formation of bladder stones. In conclusion, PA is significantly associated with risk of bladder stones.

Hypokalemia in Patients with COVID-19

BACKGROUND

Patients with COVID-19 experience multiple clinical conditions that may cause electrolyte imbalances. Hypokalemia is a concerning electrolyte disorder closely associated with severe complications. This study aimed to estimate prevalence, risk factors and outcome of hypokalemia in a cohort of patients with confirmed COVID-19.

METHODS

A retrospective analysis was conducted on 290 non-ICU admitted patients with COVID-19 at the tertiary teaching hospital of Modena, Italy, from February 16 to April 14, 2020.

RESULTS

Hypokalemia was detected in 119 out of 290 patients (41%) during hospitalization. Mean serum potassium was 3.1 ± 0.1 meq/L. The majority of patients (90.7%) patients experienced only a mild decrease in serum potassium level (3-3.4 mEq/L). Hypokalemia was associated with hypocalcemia, which was detected in 50% of subjects. Urine potassium-to-creatinine ratio, measured in a small number of patients (n = 45; 36.1%), revealed an increase of urinary potassium excretion in most cases (95.5%). Risk factors for hypokalemia were female sex (odds ratio (OR) 2.44; 95% CI 1.36-4.37; P 0.003) and diuretic therapy (OR 1.94, 95% CI 1.08-3.48; P 0.027). Hypokalemia, adjusted for sex, age and SOFA score, was not associated with ICU transfer (OR 0.52; 95% CI 0.228-1.212; P = 0.131), in-hospital mortality (OR, 0.47; 95% CI 0.170-1.324; P = 0.154) and composite outcome of ICU transfer or in-hospital mortality (OR 0.48; 95% CI 0.222-1.047; P = 0.065) in our cohort of patients.

CONCLUSIONS

Hypokalemia was a frequent disorder in subjects with COVID-19. Female sex and diuretic therapy were identified as risk factors for low serum potassium levels. Hypokalemia was unrelated to ICU transfer and death in this cohort of patients.

[Improved patient safety through a clinical decision support system in laboratory medicine]

BACKGROUND

Laboratory diagnostics are essential for diagnosis, initiation of therapy, and monitoring of patients. Laboratory results that are overlooked or incorrectly interpreted lead to adverse events and endanger patient safety. Clinical decision support systems (CDSSs) may facilitate appropriate interpretation of results and subsequent medical response.

OBJECTIVES

The research project on digital laboratory medicine (AMPEL) aims at developing a CDSS based on laboratory diagnostics, which supports practitioners in ensuring the necessary medical consequences.

MATERIALS AND METHODS

A literature review of CDSSs describes the current state of research. The research project AMPEL is presented with its objectives, challenges, and first results. Furthermore, the development of a framework and reporting system is illustrated through the clinical example of severe hypokalemia.

RESULTS AND CONCLUSION

Through interdisciplinary development and constant optimization, a specific CDSS with high acceptance among clinicians was developed. Initial results in the case of severe hypokalemia show a positive effect on patient care. Thereby, more complex frameworks such as sepsis diagnostics or acute coronary syndrome are implemented. The limited availability of standardized and digital clinical data is challenging. In addition to the application of classic decision trees in CDSS, the use of machine learning offers a promising perspective for future developments.

Metabolic alkalosis is related to delayed response to treatment of hypokalemia in non-surgical critically ill patients

Background: Potassium (K+) homeostasis is closely related to acid - base disorders. The aim of this study is to analyze the possible causes of hypokalemia non-surgical critically ill patients including acid - base disorders and its relationship with response to K+ supplementation. Methods: We performed a retrospective cohort study of 122 consecutive non-surgical patients admitted to the Intensive Care Unit during July 2016 Patients were classified according to the presence of hypokalemia or not. Demographic data, morbidities associated with hypokalemia, with emphasis in acid-base disorders and response to treatment were described and analyzed. Results: Hypokalemia was observed in 32,7% (n = 40) of the patients included. Hypokalemic group had a higher value of base excess (median of -0.65 [IQR -3.3-5.2] Vs -3.2 [IQR -5.1--1.4]; p < 0.001). The patients with hypokalemia that achieved normal serum K+ in more than 25 h had a higher value of excess base than those who did so in less than 24 h (median of 4.3 [IQR -2.1-5.5] vs -1.9 [IQR -4.8-3]; p < 0.05). Neither the degree of hypokalemia, the time to development, route of administration or solution concentration, speed of infusion, the amount of K+ administered per day per kg of weight were related with the response of treatment. Conclusions: Hypokalemia is a common disorder in non-surgical critically ill patients. Hypokalemic patients had a higher incidence of metabolic alkalosis. Patients with hypokalemia and metabolic alkalosis needed a higher amount of potassium administration and higher time to achieve correction.

Familial hypokalemic periodic paralysis in pregnancy: A case report

Familial hypokalemic periodic paralysis (f-hypoPP) is a rare neuromuscular disorder causing intermittent muscle paralysis. Pregnancy can exacerbate f-hypoPP, yet obstetric management is not well documented. We present a case of a nulliparous woman with f-hypoPP, outlining a complete prenatal care plan generalizable to other women with known f-hypoPP. To our knowledge, this is the first obstetric f-hypoPP case to prioritize intrapartum oral potassium over intravenous potassium, as well as to outline the importance of multidisciplinary care. The patient had a spontaneous vaginal delivery at term with an uneventful postpartum period. Muscle weakness and episodes of relative hypokalemia in the second trimester and during labor were effectively treated with oral potassium supplementation. Care was provided by a multidisciplinary team, and caution was taken to avoid known triggers of paralytic episodes.

Distal renal tubular acidosis and severe hypokalemia: a case report and review of the literature

Background

Distal renal tubular acidosis is a relatively infrequent condition with complex pathophysiology that can present with life-threatening electrolyte abnormalities.

Case presentation

We describe a case of a 57-year-old Caucasian woman with previous episodes of hypokalemia, severe muscle weakness, and fatigue. Upon further questioning, symptoms of dry eye and dry mouth became evident. Initial evaluation revealed hyperchloremic metabolic acidosis, severe hypokalemia, persistent alkaline urine, and a positive urinary anion gap, suggestive of distal renal tubular acidosis. Additional laboratory workup and renal biopsy led to the diagnosis of primary Sjögren’s syndrome with associated acute tubulointerstitial nephritis. After potassium and bicarbonate supplementation, immunomodulatory therapy with hydroxychloroquine, azathioprine, and prednisone was started. Nonetheless, her renal function failed to improve and remained steady with an estimated glomerular filtration rate of 42 ml/min/1.73 m². The literature on this topic was reviewed.

Conclusions

Cases of renal tubular acidosis should be carefully evaluated to prevent adverse complications, uncover a potentially treatable condition, and prevent the progression to chronic kidney disease. Repeated episodes of unexplained hypokalemia could be an important clue for diagnosis.

Severe hypokalemia with cardiac arrest as an unusual manifestation of alcoholism

Introduction: Unhealthy use of alcohol can be associated with serious adverse events. Patients with alcoholism and malnutrition are at high risk for electrolyte disturbances, commonly hypokalemia. Here in we describe a case of alcohol use disorder presented with weakness and subsequently developed cardiac arrest secondary to severe hypokalemia. Case description: A 51-year-old lady presented to our emergency department because of generalized body ache and marked weakness in both lower extremities for two days duration. She had a long-term history of alcoholism, consuming two to three pints of vodka every day for about 20 years. Her last drink of alcohol was about 48 hours prior to presentation. Her examination revealed bilateral lower limb weakness of 4/5, with intact sensory system and reflexes. Biochemical analysis of the serum showed severe electrolytes disturbance, a potassium level of 2.3 mmol/L (reference 3.6-5.1 mmol/L). Electrocardiogram (ECG) showed no arrhythmias, but changes characteristic of hypokalemia with marked corrected QT segment prolongation (QTc 551ms). Aggressive supplementation of electrolytes was initiated, however, potassium level failed to increase and subsequently she had a sinus bradycardia followed by cardiac arrest. Cardiopulmonary resuscitation was initiated, return of spontaneous circulation was obtained. During the following days, potassium supplementation was continued to achieve normal plasma potassium level. She was then discharged from the hospital with recommendations for abstinence from alcohol. Conclusion: Patients with chronic alcohol-use can have serious electrolyte disturbances including hypokalemia which can have life-threatening consequences. Prolonged potassium supplementation over several days is required to achieve normal level of plasma potassium and replenish total-body potassium deficit.

Licorice-induced apparent mineralocorticoid excess compounded by excessive use of terbutaline and high water intake

This case highlights the clinical course of a 54-year-old male patient presenting with hypertension and long-term refractory hypokalaemia. He reported long-term malaise, fatigue and physical discomfort. Diarrhoea, vomiting, over-the-counter drugs, dietary supplements and any kind of medical abuse were all denied. Physical examination was normal. Suppressed plasma renin activity along with a low aldosterone level and elevated urinary cortisone/cortisol metabolite excretion ratio raised the suspicion of apparent mineralocorticoid excess (AME). The patient started treatment with spironolactone, but serum potassium levels were persistently fluctuating and the patient was hospitalised for further evaluation. During hospitalisation, repeated medical history and diagnostic examinations revealed licorice-induced AME complicated by excessive use of terbutaline and massive water intake. Licorice discontinuation, reduction of terbutaline and normalisation of water intake led to fully normalised potassium levels. Despite careful clinical history and diagnostic work-up, hospitalisation may be necessary in selected patients with long-term hypokalaemia.

Effect of Hypokalemia on Functional Outcome at 3 Months Post-Stroke Among First-Ever Acute Ischemic Stroke Patients

Background

Hypokalemia has been confirmed to be a predictor of adverse cardiovascular and renal outcomes. There is a paucity of studies focusing on the potential connection between the serum K⁺ level and the outcome after acute ischemic stroke (AIS). This study investigated whether hypokalemia in the acute stroke stage contributes to worse functional outcome in AIS patients.

Material/Methods

This retrospective cohort study included consecutive patients with first-ever AIS admitted between June 2015 and March 2016. Patients were divided into 2 groups: hypokalemia (K⁺ <3.5 mmol/L) and normokalemia (3.5 mmol/L ≤K⁺ ≤5.5 mmol/L). Primary outcome measure was poor outcome at 3 months (modified Rankin scale >2). Univariate and multivariate logistic regression analyses were used to assess the association between hypokalemia and poor outcome. Receiver operating curve (ROC) analysis was performed to determine the optimal cutoff point of serum K⁺ level for predicting poor outcome.

Results

The percent of patients with poor outcome at 3 months was higher in the hypokalemic group (62.9%) than in the normokalemic group (45.5%). Hypokalemic patients tended to have lower fasting glucose at admission, lower Glasgow coma scale score, and longer time from symptom onset to treatment compared with normokalemic patients. Hypokalemia was associated with poor outcome at 3 months after adjusting for potential confounders (odds ratio=2.42, 95% confidence interval=1.21–4.86, P=0.013). ROC analysis showed that the optimal threshold for serum K⁺ level was 3.7 mmol/L.

Conclusions

Hypokalemia at the initial admission is associated with poor prognosis at 3 months in first-ever AIS patients.

Ileus in children presenting with diarrhea and severe acute malnutrition: A chart review

Background

Severely malnourished children aged under five years requiring hospital admission for diarrheal illness frequently develop ileus during hospitalization with often fatal outcomes. However, there is no data on risk factors and outcome of ileus in such children. We intended to evaluate predictive factors for ileus during hospitalization and their outcomes.

Methodology/Principal findings

This was a retrospective chart review that enrolled severely malnourished children under five years old with diarrhea, admitted to the Dhaka Hospital of the International Centre for Diarrhoeal Disease Research, Bangladesh between April 2011 and August 2012. We used electronic database to have our chart abstraction from previously admitted children in the hospital. The clinical and laboratory characteristics of children with (cases = 45), and without ileus (controls = 261) were compared. Cases were first identified by observation of abnormal bowel sounds on physical examination and confirmed with abdominal radiographs. For this comparison, Chi-square test was used to measure the difference in proportion, Student’s t-test to calculate the difference in mean for normally distributed data and Mann-Whitney test for data that were not normally distributed. Finally, in identifying independent risk factors for ileus, logistical regression analysis was performed. Ileus was defined if a child developed abdominal distension and had hyperactive or sluggish or absent bowel sound and a radiologic evidence of abdominal gas-fluid level during hospitalization. Logistic regression analysis adjusting for potential confounders revealed that the independent risk factors for admission for ileus were reluctance to feed (odds ratio [OR] = 3.22, 95% confidence interval [CI] = 1.24–8.39, p = 0.02), septic shock (OR = 3.62, 95% CI = 1.247–8.95, p<0.01), and hypokalemia (OR = 1.99, 95% CI = 1.03–3.86, p = 0.04). Mortality was significantly higher in cases compared to controls (22% vs. 8%, p<0.01) in univariate analysis; however, in multivariable regression analysis, after adjusting for potential confounders such as septic shock, no association was found between ileus and death (OR = 2.05, 95% CI = 0.68–6.14, p = 0.20). In a separate regression analysis model, after adjusting for potential confounders such as ileus, reluctance to feed, hypokalemia, hypocalcemia, and blood transfusion, septic shock (OR = 168.84, 95% CI = 19.27–1479.17, p<0.01) emerged as the only independent predictor of death in severely malnourished diarrheal children.

Conclusions/Significance

This study suggests that the identification of simple independent admission risk factors for ileus and risk factors for death in hospitalized severely malnourished diarrheal children may prompt clinicians to be more vigilant in managing these conditions, especially in resource-limited settings in order to decrease ileus and ileus-related fatal outcomes in such children.

Childhood malnutrition and diarrhea are important problems in lower and middle-income countries, including Bangladesh. Severe acute malnutrition (SAM) and diarrhea are responsible for more than one third of all deaths in children below five years old globally. Most of these deaths occur because of complications of SAM and/or diarrhea. SAM and diarrhea may simultaneously present in a child, often with serious complications. Ileus is a common fatal complication in such hospitalized children, and is accompanied by abdominal distension and hyperactive, sluggish, or absent bowel sounds heard using a stethoscope. Ileus is confirmed by radiologic evidence of multiple gas-fluid levels in the abdomen. However, the underlying factors contributing to ileus and its management in diarrheal children with severe acute malnutrition is unknown. Our study aimed to ascertain these risk factors and the outcome of ileus in such children by reviewing the data of previously admitted children between April 2011 and August 2012. Of 306 severely malnourished Bangladeshi under-five-year-old children with diarrhea enrolled for 17 months, 45 had ileus. Ileus was independently associated with a reluctance to feed, septic shock, and hypokalemia and had a higher case-fatality rate compared to those without ileus.