{"id":10215,"date":"2026-06-22T00:05:01","date_gmt":"2026-06-22T08:05:01","guid":{"rendered":"https:\/\/www.osmosis.org\/blog\/?p=10215"},"modified":"2026-05-29T16:06:36","modified_gmt":"2026-05-30T00:06:36","slug":"pance-question-of-the-day-diabetic-ketoacidosis","status":"publish","type":"post","link":"https:\/\/www.osmosis.org\/blog\/pance-question-of-the-day-diabetic-ketoacidosis","title":{"rendered":"PANCE\u00ae Question of the Day: Diabetic ketoacidosis"},"content":{"rendered":"<div id=\"ez-toc-container\" class=\"ez-toc-v2_0_80 ez-toc-wrap-center counter-hierarchy ez-toc-counter ez-toc-custom ez-toc-container-direction\">\n<div class=\"ez-toc-title-container\">\n<p class=\"ez-toc-title\" style=\"cursor:inherit\">In This Article<\/p>\n<span class=\"ez-toc-title-toggle\"><a href=\"#\" class=\"ez-toc-pull-right ez-toc-btn ez-toc-btn-xs ez-toc-btn-default ez-toc-toggle\" aria-label=\"Toggle Table of Content\"><span class=\"ez-toc-js-icon-con\"><span class=\"\"><span class=\"eztoc-hide\" style=\"display:none;\">Toggle<\/span><span class=\"ez-toc-icon-toggle-span\"><svg style=\"fill: #999;color:#999\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" class=\"list-377408\" width=\"20px\" height=\"20px\" viewBox=\"0 0 24 24\" fill=\"none\"><path d=\"M6 6H4v2h2V6zm14 0H8v2h12V6zM4 11h2v2H4v-2zm16 0H8v2h12v-2zM4 16h2v2H4v-2zm16 0H8v2h12v-2z\" fill=\"currentColor\"><\/path><\/svg><svg style=\"fill: #999;color:#999\" class=\"arrow-unsorted-368013\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"10px\" height=\"10px\" viewBox=\"0 0 24 24\" version=\"1.2\" baseProfile=\"tiny\"><path d=\"M18.2 9.3l-6.2-6.3-6.2 6.3c-.2.2-.3.4-.3.7s.1.5.3.7c.2.2.4.3.7.3h11c.3 0 .5-.1.7-.3.2-.2.3-.5.3-.7s-.1-.5-.3-.7zM5.8 14.7l6.2 6.3 6.2-6.3c.2-.2.3-.5.3-.7s-.1-.5-.3-.7c-.2-.2-.4-.3-.7-.3h-11c-.3 0-.5.1-.7.3-.2.2-.3.5-.3.7s.1.5.3.7z\"\/><\/svg><\/span><\/span><\/span><\/a><\/span><\/div>\n<nav><ul class='ez-toc-list ez-toc-list-level-1 ' ><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-1\" href=\"https:\/\/www.osmosis.org\/blog\/pance-question-of-the-day-diabetic-ketoacidosis\/#The_correct_answer_to_todays_PANCE%C2%AE_Question_is%E2%80%A6\" >The correct answer to today&#8217;s PANCE\u00ae Question is&#8230;<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-2\" href=\"https:\/\/www.osmosis.org\/blog\/pance-question-of-the-day-diabetic-ketoacidosis\/#Incorrect_Answer_Explanations\" >Incorrect Answer Explanations<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-3\" href=\"https:\/\/www.osmosis.org\/blog\/pance-question-of-the-day-diabetic-ketoacidosis\/#Main_Explanation\" >Main Explanation<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-4\" href=\"https:\/\/www.osmosis.org\/blog\/pance-question-of-the-day-diabetic-ketoacidosis\/#Major_Takeaway\" >Major Takeaway<\/a><ul class='ez-toc-list-level-3' ><li class='ez-toc-heading-level-3'><a class=\"ez-toc-link ez-toc-heading-5\" href=\"https:\/\/www.osmosis.org\/blog\/pance-question-of-the-day-diabetic-ketoacidosis\/#Want_to_learn_more_about_this_topic\" >Want to learn more about this topic?<\/a><\/li><\/ul><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-6\" href=\"https:\/\/www.osmosis.org\/blog\/pance-question-of-the-day-diabetic-ketoacidosis\/#References\" >References&nbsp;<\/a><\/li><\/ul><\/nav><\/div>\n\n<p class=\"wp-block-paragraph\"><strong><em>Prepare for the PANCE\u00ae 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\u2019s find out!<\/em><\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>A 32-year-old man<\/strong> is admitted to the hospital for management of <strong>diabetic ketoacidosis.<\/strong> He is given <strong>aggressive IV fluid resuscitation with normal saline, an IV bolus of regular insulin, and placed on a continuous insulin infusion.<\/strong> After initial management, his disorientation and abdominal discomfort have resolved; however, he continues to have mild nausea. Temperature is <strong>39.2 \u00b0C (102.5 \u00b0F),<\/strong> blood pressure is <strong>88\/62 mmHg,<\/strong> pulse is <strong>130\/min,<\/strong> respiratory rate is 24\/min, and oxygen saturation is 100% on room air. His fluid was changed to <strong>5% dextrose in half-normal saline<\/strong> 2 hours ago. The most recent laboratory studies are listed below.<\/p>\n\n\n\n<figure class=\"wp-block-table\"><table class=\"has-fixed-layout\"><tbody><tr><td><strong>Laboratory study<\/strong>&nbsp;<\/td><td><strong>Result<\/strong>&nbsp;<\/td><td><strong>Reference range<\/strong>&nbsp;<\/td><\/tr><tr><td>Sodium&nbsp;<\/td><td>140&nbsp;mEq\/L&nbsp;<\/td><td>136-146&nbsp;mEq\/L&nbsp;<\/td><\/tr><tr><td>Potassium&nbsp;<\/td><td>4.0&nbsp;mEq\/L&nbsp;<\/td><td>3.5-5&nbsp;mEq\/L&nbsp;<\/td><\/tr><tr><td>Chloride&nbsp;<\/td><td>105&nbsp;mEq\/L&nbsp;<\/td><td>95-105&nbsp;mEq\/L&nbsp;<\/td><\/tr><tr><td>Bicarbonate&nbsp;<\/td><td>10&nbsp;mEq\/L&nbsp;<\/td><td>22-28&nbsp;mEq\/L&nbsp;<\/td><\/tr><tr><td>Glucose&nbsp;<\/td><td>188 mg\/dL&nbsp;<\/td><td>70-110 mg\/dL&nbsp;<\/td><\/tr><tr><td>Venous pH&nbsp;<\/td><td>7.28&nbsp;<\/td><td>7.35-7.45&nbsp;<\/td><\/tr><\/tbody><\/table><\/figure>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Which of the following adjustments should be made to the current management?<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>A. Continue 5% dextrose in half-normal saline<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>B. Add potassium to the IV fluid<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>C. Discontinue IV fluids<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>D. Discontinue the insulin infusion<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>E. Add sodium bicarbonate to the IV fluid<\/strong><\/p>\n\n\n\n<p class=\"has-text-align-center wp-block-paragraph\"><em>Scroll down to find the answer!&nbsp;<\/em><\/p>\n\n\n\n<figure class=\"wp-block-embed is-type-video is-provider-youtube wp-block-embed-youtube wp-embed-aspect-16-9 wp-has-aspect-ratio\"><div class=\"wp-block-embed__wrapper\">\n<iframe loading=\"lazy\" title=\"Everybody loves Osmosis.org\" width=\"500\" height=\"281\" src=\"https:\/\/www.youtube.com\/embed\/kizbJZ9cdLg?feature=oembed\" frameborder=\"0\" allow=\"accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share\" referrerpolicy=\"strict-origin-when-cross-origin\" allowfullscreen><\/iframe>\n<\/div><\/figure>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"The_correct_answer_to_todays_PANCE%C2%AE_Question_is%E2%80%A6\"><\/span>The correct answer to today&#8217;s PANCE\u00ae Question is&#8230;<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>B. Add potassium to the IV fluid<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Correct: <\/strong>See Main Explanation.<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Incorrect_Answer_Explanations\"><\/span>Incorrect Answer Explanations<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>A. Continue 5% dextrose in half-normal saline<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Incorrect:<\/strong> Despite the patient\u2019s 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.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>C. Discontinue IV fluids<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Incorrect:<\/strong> This patient is still in diabetic ketoacidosis, as evidenced by the high anion gap metabolic acidosis. Continued insulin and IV fluid hydration are needed.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>D. Discontinue the insulin infusion<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Incorrect:<\/strong> Despite the fact that the patient\u2019s glucose is &lt;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.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>E. Add sodium bicarbonate to the IV fluid<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Incorrect:<\/strong> Sodium bicarbonate is typically only required in severe acidosis where the patient\u2019s blood pH is &lt;6.9. Management of acidosis in DKA centers around treating the underlying insulin deficiency causing the excess ketone production.\u00a0<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Main_Explanation\"><\/span>Main Explanation<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Management of diabetic ketoacidosis (DKA) typically requires insulin administration and IV fluid resuscitation.<\/strong> IV insulin not only decreases serum glucose levels by allowing the uptake of glucose into cells, but it also <strong>inhibits ketogenesis.<\/strong> The ketones in the system are then cleared through the kidneys. <strong>IV fluid is important in the correction of volume depletion, which is caused by osmotic diuresis in DKA.<\/strong> Oftentimes, the patient\u2019s blood glucose level will correct before their <strong>high anion gap metabolic acidosis resolves.<\/strong> In this circumstance, <strong>dextrose is added to the IV fluid while the patient remains on the insulin infusion in order to prevent hypoglycemia.<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Additionally, <strong>electrolyte monitoring and management of abnormalities is an essential part of the management of DKA.<\/strong> 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. <strong>As insulin is infused and the acidosis is corrected, potassium shifts back into the cells and can lead to hypokalemia.<\/strong> Thus, it is important to monitor and provide potassium supplementation to prevent dangerous complications resulting from hypokalemia.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Laboratory studies, including electrolytes, are typically monitored every 2\u20134 hours during the treatment period for DKA.<\/strong> 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, <strong>insulin should be temporarily held until adequate replacement is achieved.<\/strong> Even levels within the normal range require supplementation. However, this can easily be achieved by adding potassium to the patient\u2019s IV fluid without disrupting the continuous insulin infusion.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Once the patient\u2019s glucose is stabilized and the <strong>high anion gap acidosis has resolved<\/strong>, the patient can be transitioned to <strong>subcutaneous insulin.<\/strong> This usually requires a <strong>1\u20132 hour overlap between IV insulin and subcutaneous insulin<\/strong>, with close monitoring of blood glucose levels.<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Major_Takeaway\"><\/span>Major Takeaway<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>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.<\/strong><\/p>\n\n\n\n<h3 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Want_to_learn_more_about_this_topic\"><\/span>Want to learn more about this topic?<span class=\"ez-toc-section-end\"><\/span><\/h3>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Review this Osmosis content: <a href=\"https:\/\/www.osmosis.org\/learn\/Diabetic_ketoacidosis:_Clinical_sciences\">Diabetic ketoacidosis: Clinical sciences<\/a><\/strong><\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"References\"><\/span>References&nbsp;<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Blonde, L., et al. (2022). <strong>American Association of Clinical Endocrinology clinical practice guideline: Developing a diabetes mellitus comprehensive care plan \u2013 2022 update.<\/strong> Endocrine Practice, 28(10):923\u20131049. <a href=\"https:\/\/www.endocrinepractice.org\/article\/S1530-891X(22)00576-6\/fulltext\">https:\/\/www.endocrinepractice.org\/article\/S1530-891X(22)00576-6\/fulltext<\/a><\/li>\n\n\n\n<li>Eledrisi, M.S., and Elzouki, A. (2020). <strong>Management of diabetic ketoacidosis in adults: A narrative review.<\/strong><\/li>\n<\/ul>\n\n\n\n<figure class=\"wp-block-image aligncenter size-large\"><a href=\"http:\/\/osmosis.org\/plans\/pa\"><img loading=\"lazy\" decoding=\"async\" width=\"700\" height=\"250\" src=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2020\/09\/Blog_Display_Ads_MD1_2023.png?w=700\" alt=\"\" class=\"wp-image-5904\" srcset=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2020\/09\/Blog_Display_Ads_MD1_2023.png 700w, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2020\/09\/Blog_Display_Ads_MD1_2023.png?resize=300,107 300w\" sizes=\"auto, (max-width: 700px) 100vw, 700px\" \/><\/a><\/figure>\n\n\n\n<p class=\"has-text-align-center wp-block-paragraph\"><em>Want more <strong>PANCE\u00ae-style practice questions<\/strong>? Try <strong>Osmosis by Elsevier<\/strong> today! Access your&nbsp;<a href=\"http:\/\/osmosis.org\/plans\/pa\" target=\"_blank\" rel=\"noreferrer noopener\"><strong>free trial<\/strong><\/a>&nbsp;and discover why millions of current and future <strong>clinicians and caregivers<\/strong> love <strong>learning by Osmosis<\/strong>.<\/em><a href=\"https:\/\/www.osmosis.org\/plans\/rn\" target=\"_blank\" rel=\"noreferrer noopener\"><\/a><a href=\"https:\/\/www.osmosis.org\/plans\/rn\" target=\"_blank\" rel=\"noreferrer noopener\"><\/a><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><\/p>\n","protected":false},"excerpt":{"rendered":"<p>A patient with diabetic ketoacidosis improves clinically but remains acidotic and hypotensive. Can you identify the next best management step in this high-yield PANCE-style scenario?<\/p>\n","protected":false},"author":208,"featured_media":10217,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_jetpack_newsletter_access":"","_jetpack_dont_email_post_to_subs":false,"_jetpack_newsletter_tier_id":0,"_jetpack_memberships_contains_paywalled_content":false,"_jetpack_feature_clip_id":0,"_jetpack_memberships_contains_paid_content":false,"footnotes":"","jetpack_post_was_ever_published":false},"categories":[20,38,1371,37,1366],"tags":[2967,1997,3108,1131,1135,880,440,2801,1132,1137,462,1599,731,967,3137],"class_list":["post-10215","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-exam-prep","category-pance","category-pance-questions","category-pa","category-questions","tag-board-exam-prep","tag-clinical-sciences","tag-clinical-vignette","tag-diabetic-ketoacidosis","tag-dka","tag-electrolyte-management","tag-emergency-medicine","tag-endocrinology","tag-insulin-therapy","tag-metabolic-acidosis","tag-osmosis","tag-pance-prep","tag-patient-management","tag-physician-assistant-education","tag-potassium-replacement"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v23.6 - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>PANCE\u00ae Question of the Day: Diabetic ketoacidosis - Osmosis Blog<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/www.osmosis.org\/blog\/pance-question-of-the-day-diabetic-ketoacidosis\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"PANCE\u00ae Question of the Day: Diabetic ketoacidosis - Osmosis Blog\" \/>\n<meta property=\"og:description\" content=\"A patient with diabetic ketoacidosis improves clinically but remains acidotic and hypotensive. 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