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You are caring for a 12 year old known diabetic who presents in diabetic ketoacidosis. Temperature is 37.5, HR 100, RR 24, BP 96/36, O2 sat 98% on room air. Labs show glucose 550, Na – 132, K – 2.8, pH 7.09. An initial bolus of normal saline 20 mL/kg has been given.
Kelly August 5, 2020 - 9:43 am
D) Give a bolus of NS with 40 mEq/L KCl
Patients with DKA typically have a total body deficit of potassium, although measured serum potassium is often in the normal range. This is because acidosis results in intracellular shifts in electrolytes such that K+ is pushed extracellularly, registering in a “normal” measured serum potassium level. If the measured serum K+ level is very low, as in this vignette, then the total body potassium deficit is significant. Giving insulin will start to correct the acidosis, resulting in shifting of extracellular K+ to inside the cell, and serum K+ will fall further. Thus, K+ level should be corrected to at least 3.3 before adding insulin. K+ should be replaced with fluids at 40 mEq/L at a K+ rate of no > 0.5 mEq/kg/hr; another option is careful administration of 1 mEq/kg of K+ at 0.5 mEq/kg/hr (max 10 mEq/hr for an adult). Because excessive chloride can cause a non-gap hyperchloremic acidosis, some prefer to use K-Acetate 20 mEq/L and K-Phosphate 20 mEq/L. Bicarbonate therapy does not have a role in pediatric DKA management, and bicarbonate’s improvement of the serum acidosis would also worsen the hypokalemia.