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Diabetic ketoacidosis — ABIM Board MCQ

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HardEndocrinology/MetabolismDiabetic ketoacidosisABIM Board

A 23-year-old with DKA has received initial fluid and insulin. Glucose has fallen to 220 mg/dL, but beta-hydroxybutyrate remains elevated and venous pH is 7.20. What adjustment is most appropriate?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: B — Add dextrose-containing intravenous fluid and continue insulin until ketoacidosis resolves

The best answer is “Add dextrose-containing intravenous fluid and continue insulin until ketoacidosis resolves”. Insulin must continue until ketoacidosis resolves, not merely until glucose normalizes. Dextrose is added as glucose falls so insulin can suppress ketogenesis without causing hypoglycemia. A sulfonylurea does not treat DKA, dextrose-free fluid makes ongoing insulin unsafe, and bicarbonate is not routinely indicated at this pH.

Reference: 2024 Consensus Report on Hyperglycemic Crises in Adults: https://diabetesjournals.org/care/article/47/8/1257/156808/Hyperglycemic-Crises-in-Adults-With-Diabetes-A