Prepare for the PANCE® with this clinical scenario involving a patient being treated for diabetic ketoacidosis who remains hypotensive and febrile despite initial improvement. What are the next best steps based on his evolving clinical status and laboratory findings? Let’s find out!
A 32-year-old man is admitted to the hospital for management of diabetic ketoacidosis. He is given aggressive IV fluid resuscitation with normal saline, an IV bolus of regular insulin, and placed on a continuous insulin infusion. After initial management, his disorientation and abdominal discomfort have resolved; however, he continues to have mild nausea. Temperature is 39.2 °C (102.5 °F), blood pressure is 88/62 mmHg, pulse is 130/min, respiratory rate is 24/min, and oxygen saturation is 100% on room air. His fluid was changed to 5% dextrose in half-normal saline 2 hours ago. The most recent laboratory studies are listed below.
| Laboratory study | Result | Reference range |
| Sodium | 140 mEq/L | 136-146 mEq/L |
| Potassium | 4.0 mEq/L | 3.5-5 mEq/L |
| Chloride | 105 mEq/L | 95-105 mEq/L |
| Bicarbonate | 10 mEq/L | 22-28 mEq/L |
| Glucose | 188 mg/dL | 70-110 mg/dL |
| Venous pH | 7.28 | 7.35-7.45 |
Which of the following adjustments should be made to the current management?
A. Continue 5% dextrose in half-normal saline
B. Add potassium to the IV fluid
C. Discontinue IV fluids
D. Discontinue the insulin infusion
E. Add sodium bicarbonate to the IV fluid
Scroll down to find the answer!
The correct answer to today’s PANCE® Question is…
B. Add potassium to the IV fluid
Correct: See Main Explanation.
Incorrect Answer Explanations
A. Continue 5% dextrose in half-normal saline
Incorrect: Despite the patient’s normal potassium, he still has a high anion gap metabolic acidosis. With the continued insulin infusion and correction of the acidosis, additional potassium supplementation will be needed.
C. Discontinue IV fluids
Incorrect: This patient is still in diabetic ketoacidosis, as evidenced by the high anion gap metabolic acidosis. Continued insulin and IV fluid hydration are needed.
D. Discontinue the insulin infusion
Incorrect: Despite the fact that the patient’s glucose is <200 mg/dL, he is still in diabetic ketoacidosis, as evidenced by the high anion gap metabolic acidosis. Continued insulin and IV fluid hydration are needed.
E. Add sodium bicarbonate to the IV fluid
Incorrect: Sodium bicarbonate is typically only required in severe acidosis where the patient’s blood pH is <6.9. Management of acidosis in DKA centers around treating the underlying insulin deficiency causing the excess ketone production.
Main Explanation
Management of diabetic ketoacidosis (DKA) typically requires insulin administration and IV fluid resuscitation. IV insulin not only decreases serum glucose levels by allowing the uptake of glucose into cells, but it also inhibits ketogenesis. The ketones in the system are then cleared through the kidneys. IV fluid is important in the correction of volume depletion, which is caused by osmotic diuresis in DKA. Oftentimes, the patient’s blood glucose level will correct before their high anion gap metabolic acidosis resolves. In this circumstance, dextrose is added to the IV fluid while the patient remains on the insulin infusion in order to prevent hypoglycemia.
Additionally, electrolyte monitoring and management of abnormalities is an essential part of the management of DKA. In DKA, potassium shifts out of cells due to metabolic acidosis, and some potassium then leaves the body through the kidneys. In laboratory studies, the serum potassium may appear high or normal despite the overall deficiency. As insulin is infused and the acidosis is corrected, potassium shifts back into the cells and can lead to hypokalemia. Thus, it is important to monitor and provide potassium supplementation to prevent dangerous complications resulting from hypokalemia.
Laboratory studies, including electrolytes, are typically monitored every 2–4 hours during the treatment period for DKA. If the potassium level is above the reference range, no replacement is required (but monitoring should still continue). In cases where the potassium level drops below the reference range, insulin should be temporarily held until adequate replacement is achieved. Even levels within the normal range require supplementation. However, this can easily be achieved by adding potassium to the patient’s IV fluid without disrupting the continuous insulin infusion.
Once the patient’s glucose is stabilized and the high anion gap acidosis has resolved, the patient can be transitioned to subcutaneous insulin. This usually requires a 1–2 hour overlap between IV insulin and subcutaneous insulin, with close monitoring of blood glucose levels.
Major Takeaway
Due to cellular shifts in potassium associated with acidosis and insulin, potassium supplementation is often required in the management of DKA, even if the level is within the normal reference range.
Want to learn more about this topic?
Review this Osmosis content: Diabetic ketoacidosis: Clinical sciences
References
- Blonde, L., et al. (2022). American Association of Clinical Endocrinology clinical practice guideline: Developing a diabetes mellitus comprehensive care plan – 2022 update. Endocrine Practice, 28(10):923–1049. https://www.endocrinepractice.org/article/S1530-891X(22)00576-6/fulltext
- Eledrisi, M.S., and Elzouki, A. (2020). Management of diabetic ketoacidosis in adults: A narrative review.
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