A 24-year-old man with a history of type 1 diabetes mellitus is brought to the emergency department due to altered mental status, vomiting, and abdominal pain. His vital signs show a heart rate of 128/min and blood pressure of 90/60 mm Hg. Laboratory evaluation reveals a blood glucose of 650 mg/dL, an arterial pH of 7.15, a serum bicarbonate of 10 mEq/L, and a serum potassium of 4.5 mEq/L. A diagnosis of diabetic ketoacidosis (DKA) is made.
Arrange the following steps in the correct chronological order for the initial and ongoing management of this patient's condition.
- 1Administer a rapid intravenous bolus of 0.9% normal saline
- 2Initiate a continuous intravenous infusion of regular insulin
- 3Add 5% dextrose to the intravenous fluids
- 4Discontinue the intravenous insulin infusion and transition to subcutaneous insulin
Answer
The correct sequence for the management of diabetic ketoacidosis is: 1) Administer a rapid intravenous bolus of 0.9% normal saline, 2) Initiate a continuous intravenous infusion of regular insulin, 3) Add 5% dextrose to the intravenous fluids, 4) Discontinue the intravenous insulin infusion and transition to subcutaneous insulin.
The management of DKA follows a strict sequential algorithm to optimize metabolic recovery and minimize complications. 1) High-volume isotonic saline is always the first step to restore vascular volume and renal perfusion. 2) Intravenous regular insulin is initiated only after confirming serum potassium is > 3.3 mEq/L (in this patient it is 4.5 mEq/L, so insulin can be safely started alongside potassium replacement). 3) Once blood glucose drops below 200-250 mg/dL, 5% dextrose is added to the IV fluids. This prevents hypoglycemia and allows the insulin infusion to be continued until the anion gap closes. 4) Finally, once the anion gap has closed and the patient can eat, subcutaneous insulin is administered, and the IV infusion is stopped 1-2 hours later.
Step-by-Step Solution
Key Concept
Management algorithm for Diabetic Ketoacidosis (DKA)
Estimated Time:1m 30s