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DKA with severe hypokalaemia — SCE Acute Medicine MCQ

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HardDiabetes and endocrine medicineDKA with severe hypokalaemiaSCE Acute Medicine

A 63-year-old man with type 1 diabetes is admitted with DKA. Initial potassium is 3.1 mmol/L, pH 7.12, bicarbonate 8 mmol/L and ketones 6.8 mmol/L. He is dehydrated but has passed urine. What is the most appropriate next step regarding insulin and potassium?

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

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Correct answer: B — Replace potassium first and delay fixed-rate insulin until potassium is above 3.5 mmol/L

In DKA, insulin drives potassium intracellularly and can precipitate dangerous hypokalaemia if started when potassium is very low. JBDS guidance supports potassium replacement and delaying insulin until potassium is safely above the threshold, while continuing careful fluid resuscitation. Calcium gluconate stabilises myocardium in hyperkalaemia, not hypokalaemia.

Reference: JBDS DKA Guideline 2023