Review Question - QID 100567

In a child presenting with diabetic ketoacidosis (DKA), the appropriate treatment is administration of IV fluids and insulin. This will result in potassium influx into cells, resulting in a decrease in serum potassium.

Generally, whole body potassium in patients with DKA is relatively low (3-5 mEq per L). Acidosis increases serum potassium levels (often causing serum potassium to appear normal or high). However, acidosis is not the only cause. Insulin deficiency and hyperosmolality also contribute to hyperkalemia. Insulin administration results in a decrease in serum potassium (as potassium ions are driven into cells) and may ultimately result in hypokalemia.

As reviewed by Trachtenbarg, potassium should be started in patients with DKA as soon as adequate urine output is confirmed and the potassium level is <5 mEq per L. If the serum potassium level is <3.3 mEq per L, potassium replacement should be given immediately and insulin should be held until the potassium level is >3.3 mEq per L.

Klocker et al. review the utility of ß-hydroxybutyrate as the best measurement of the degree of ketosis. In the conclusion of their systematic review of RCTs and cohort studies, the authors suggest that blood ß-hydroxybutyrate testing is more effective than urine acetoacetate testing in reducing emergency department assessment time, duration of hospitalization, and time to recovery from diabetic ketoacidosis, as well as potentially lowering healthcare expenditure.

Incorrect answers:
Answer 1: Insulin will enable glucose to enter cells, thus decreasing serum glucose.
Answer 2: Insulin and fluids will help to restore the anion-gap metabolic acidosis back to physiologic conditions.
Answer 4: Resolving the metabolic acidosis will result in an increase in the pH.
Answer 5: Resolution of the acidosis following treatment with insulin and fluids will ultimately result in an increase in serum bicarbonate back to normal levels.