The severity of the diarrhea still makes me very nervous to suspect a straight forward problem of simple diarrhea causing hypokalemia causing paralysis. There is severe failure to thrive (is it pure malnutrition, hence I need to know the calorie intake), is it due to persistent acidosis as in Renal tubular dysfunction (is there clinical rickets inspite of low urine output documented at this episode), metabolic acidosis anion gap unclear with the absence of Cl levels but is more likely to be high. In the presence of severe acidosis the true potassium deficit must be even more severe than indicated since there is even less inside the cells in acidosis. Watch for Hypocalcemic spasms during correction of Potassium. With such severe hypokalemia one common complication noticed during correction is the fact that polyuria may become a probelm since Potassium is also needed for the functioning of the renal tubules. I would continue correction of Potassium IV in view of the severeity and change to oral as soon as possible. I would use Calcium in anticipation of hypocalemia during correction of acidosis. I would correct Acidosis with Bicarboante and IV fluids for dehydration correction apart from giving Oxygen. I would still look for evidence of RTA underlying if there is no evidence of true malnutrition by diet recall and in the presence of polyuria or rickets - clinical or biochemical. The significant dimorphic anemia comlicates the picture but certainly points towards MALNUTRITION being the true underlying pathology much to my "theories" of the kidney origin! May be the patinet is trying to tell me that the child is a pure PEM with recurrent GI infections and now with Hypokalemic paralysis secondary to acute GE.
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