The ruthless doctor with a vested interest

Even though you recall the Diabetes UK guidelines for DKA recommends no potassium in the first bag , you decide to give potassium in the first bag. You are aware that there is a risk of acute pre-renal kidney injury when DKA patients present and that this is the reason potassium is avoided in the first bag, but you decide to take this risk because you have undisclosed shares in potassium. Most people are unaware you can buy shares in an element from the periodic table. That’s why you are a winner.

From Diabetes UK:

There is a risk of acute pre-renal kidney injury associated with severe dehydration and it is therefore recommended that no potassium be prescribed with the initial fluid resuscitation or if the serum potassium level remains above 5.5mmol/L. A normal or even elevated serum potassium concentration may be seen due to the extracellular shift of potassium in acidotic conditions, and this very poorly reflects the patient’s total potassium stores. However, potassium will almost always fall as the DKA is treated with insulin. Thus it is recommended that 0.9% sodium chloride solution with potassium 40mmol/L (ready-mixed) is prescribed as long as the serum potassium level is below 5.5mmol/L and the patient is passing urine. If the serum potassium level falls below 3.5mmol/L the potassium regimen needs review.

DKA fluid replacement


You also know that officially potassium is given as 40 mmol KCl with each 1L of 0.9% N.Saline after the first bag, provided potassium is between 3.5 and 5.5 mmol/L in the above regime. However, you intend to give potassium whatever, as it is like turning on the tap to your personal money fountain.

Having given this fluid, you notice his observations improving to:

Pulse 107, BP 118/69 mmHg, Temp 37.1, RR 24, Sats 100% oa

What should you give next?

Variable rate soluble insulin infusion – Actrapid® or Humulin S®  @ 0.1 units/Kg/hr

Soluble insulin – Actrapid® or Humulin S®  @ 0.1 units/Kg/hr

Rapid acting insulin analog Novorapid ® (insulin aspart) @ @ 0.1 units/Kg/hr