doc_clotaire
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A 15-year-old boy is brought to the emergency department by his father because the boy is slightly lethargic and has labored breathing. The father, who is a single parent, reports that the boy is "always thirsty" and "urinates a lot." The boy's pulse is 120/min, respirations are 32/min and blood pressure is 110/65 mm Hg. Laboratory studies show:
Serum
Na+ 132 mEq/L
K+ 4.1 mEq/L
Cl! 92 mEq/L
HCO3
! 6.6 mEq/L
Creatinine 1.0 mg/dL
Glucose 850 mg/dL
The boy is treated with intravenous insulin and isotonic saline solution. Several hours later, he is improved and his serum
glucose concentration is 450 mg/dL. Which of the following is the most appropriate next step?
(A) Add glucose to this intravenous solution
(B) Add potassium to this intravenous solution
(C) Add sodium bicarbonate to this intravenous solution
(D) Begin treatment with intermediate-acting insulin
(E) Change the intravenous solution to hypotonic saline solution
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| new_n_lost
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(B) Add potassium to this intravenous solution
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| Justice
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new_n_lost wrote:
(B) Add potassium to this intravenous solution
Positively agree
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| dr.wad
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B_ we have just taken a good lecture in Tx of DKA
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| darkhorse
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agreed...insulin will cause intracellular shift of K+
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| doc_clotaire
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Bravo Justice 
You got it !
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| Adam
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Thanks for both useful questions about DKA .. I won't forget the K any more
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| doc_clotaire
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That 's the idea Adam !
We all are here to lurn from each other so we can be better Doctors in the future !
You are very welcome buddy 
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| sprint123
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clotaire..U rock with ur questions!!!
Can u tell me when should we start intermediate insulin therapy rather than continuous intravenous in DKA?? AND
Should we add K+ only after the patient settles down or his glucose level comes down??
Thanx
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| vradojc1
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"After anion gap has been corrected and patient can tolerate PO intake, give 4-10 U regular and some long acting insulin and turn off the insulin drip ~2 h later."
From Blueprints clinical cases in Medicine - great book!
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| doc_clotaire
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Sprint , to answer your question , here is my humble way to deal with this kind of questions on the boards  FOR BOARD PURPOSE , you must do all that in that order
1 ) Admit to ICU <?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" />
2 ) IV insulin and 0.9 % normal saline , as those patients are often dehydrated ( That is the next BEST step in management of DKA) but they can get real tricky with you so you must know when it ‘s appropriate to apply which each one of them . i , e if they ask you Which one between those 2 is the most important ?
For board purpose , It ‘s IV Insulin immediately after the diagnosis is established .. Why ? because they want you to know that no matter how much fluids you give those patients, you WILL NOT reverse the DKA state without IV INSULIN due to the pathophysiology of DKA ( lack of insulin ) , so insulin is vital for DKA patients .
What I am trying to say is , we have to be very carefull on they way of answering this kind of questions as the question writers can get us easily confused  .
3 ) K replacement should be started from the beginning only if the serum K is normal or low but never add K if more than 5 ,meq/L , it ‘s no no in USMLE . So if they question stem say :
Add fluids and K ( while K is more than 5 me/L) or Give IV Insulin
Stick to IV insulin
4 ) Look for Pseudonatremia ( as glucose goes up , NA will go down )
5 ) Look for a precipitating cause like infection as infections related stress can realease cortisol which put higher insulin requirement ( most common is UTI due to E.Coli ans Staph Saprofyticus in sexually active woman and Pneumonias)
6 ) For Boad Purpose , never give Bicarbonate
Morale of the Story !
a good way to remember them for CK is
NSIM of DKA ……Insulin , Insulin , Insulin , Insulin , Insulin and Fluids
While for Hyperosmolar Nonketotic Coma
NSIM of HONK……Fluid, Fluid , Fluid , Fluid , Fluid , Fluid and Insulin
I hope that answer your question buddy !
Good Luck and Happy Studying Sprint
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| vanshita
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thank you GOOD explanation
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| ram3
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I agree the answer is(B) Add potassium to this intravenous solution because insulin causes a trancellular shift and leads to hypokalemia on the ecg there will be u wave and the management is adding potassium
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| DrVirgo
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Good question and explanation.
The way I remember it is that INsulin puts K IN cells, thus causing hypokalemia, so we have to add potassium!
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| neuroblastoma
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thanksssssssssssssssss
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| titly
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nice explanation doc_clotaire
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