A 24-year-old woman with type 1 diabetes mellitus presents to the emergency department with nausea, vomiting, abdominal pain, and confusion. Her blood pressure is 90/60 mmHg, heart rate is 120/min, and respiratory rate is 26/min with deep, rapid breaths. Laboratory results show a blood glucose of 450 mg/dL, an arterial pH of 7.1, an anion gap of 22, and a serum potassium of 4.2 mEq/L. The diagnosis of diabetic ketoacidosis (DKA) is established. Arrange the following steps in the acute management of this patient in the correct chronological order.
- 1Administer a rapid intravenous bolus of 0.9% normal saline
- 2Initiate a continuous intravenous regular insulin infusion
- 3Add 5% dextrose to the intravenous fluids
- 4Transition to a subcutaneous insulin regimen
Answer
The correct sequence for DKA management is: 1) Administer a rapid intravenous bolus of 0.9% normal saline, 2) Initiate a continuous intravenous regular insulin infusion, 3) Add 5% dextrose to the intravenous fluids, and 4) Transition to a subcutaneous insulin regimen.
The standard sequence of care for diabetic ketoacidosis (DKA) begins with aggressive restoration of intravascular volume using isotonic saline (0.9% NaCl). Once volume is addressed and the laboratory interpretation confirms serum potassium is at a safe level (>3.3 mEq/L), a continuous IV regular insulin infusion is initiated to suppress lipolysis and ketogenesis. As the insulin takes effect, blood glucose levels will fall. Once glucose drops below 200-250 mg/dL, 5% dextrose must be added to the IV fluids. This provides a carbohydrate source to prevent hypoglycemia while allowing the continuous insulin drip to remain on until the anion gap completely closes. Finally, when laboratory results show a closed anion gap and corrected metabolic acidosis, and the patient is able to eat, they are transitioned to a subcutaneous insulin regimen (with a brief overlap period before stopping the IV drip).
Step-by-Step Solution
Key Concept
Diabetic Ketoacidosis (DKA) Management Sequence