DKA Management

[drnrpatel]

A 23-year-old woman was admitted 8 hours ago to the intensive care unit, where you just started your shift, with a diagnosis of diabetic ketoacidosis. The patient is alert and oriented to person, place, and time. She feels slightly weak and complains of nausea and abdominal discomfort. She states she went on a weekend trip and forgot to take her insulin with her. Her blood pressure is 115/85 mm Hg with no orthostatic changes. Her pulse is 85/min, respirations are 15/min, and temperature is 37.3 C (99.1 F). The rest of her physical examination is unremarkable. You have been ordering serial laboratory tests every hour, and the latest results obtained are:

PO4- : Normal
Glucose: 302 mg/dl
K+ :5.1 mEq/L

The patient is currently on no food by mouth (NPO). She has good urine output and is on an insulin drip, receiving one-half normal saline solution as intravenous fluids with potassium supplementation. After you review the above lab findings and the patient’s current treatment plan, which of the following is the best next step in the management?

A. Add 5% dextrose to the intravenous fluids
B. Add phosphate to the intravenous fluids
C. Give 20 units of insulin (NPH) subcutaneously and stop the insulin drip
D. Hold potassium replacement in the intravenous fluids
E. Start the patient on a clear liquid diet

[OzoneZone234]

D. Hold potassium replacement in the intravenous fluids

Shouldn't insulin alone be able to take care of the potassium level?

[dryogi]

D. Hold potassium replacement in the intravenous fluids

[podebrad]

D.
Would like to know the exact reasons why other options wont be correct though.

[desigrl]

D. Hold potassium replacement in the intravenous fluids

[indra2013]

A. Add 5% dextrose to the intravenous fluids

[drnrpatel]

The correct answer is D. In the management of DKA it is important to know the indication for potassium replacement. You should replace potassium in a patient with DKA only if the potassium is less than 5 and the patient has good urine output. The patient in this case has good urine output but the potassium is 5.1. Therefore, potassium replacement should be stopped at this time.
This patient’s blood glucose is over 250; therefore, it would be inappropriate to add 5% dextrose to intravenous fluids (choice A) at this time.
Adding phosphate to the IV fluids (choice B) is incorrect because phosphorus levels are normal so phosphate is not necessary at this time.
Stopping the insulin drip (choice C) is not appropriate in this patient at this time because she still has positive acetone in serum.
Starting the patient on a clear liquid diet (choice E) is incorrect. This patient is still nauseated with abdominal discomfort so it would be inappropriate to start feeding her at this time.