A 22-year-old man with type 1 diabetes presents with acute appendicitis. Blood glucose is 480 mg/dL, arterial pH 7.18, serum potassium 3.2 mEq/L and urine ketones strongly positive. The surgical team wants an appendicectomy tonight. Which is the MOST appropriate anaesthetic plan?
- A Proceed immediately with rapid sequence induction
- B Start intravenous fluids, insulin infusion and potassium replacement, then proceed once acidosis is improving and potassium is corrected ✓
- C Cancel surgery until blood glucose falls below 150 mg/dL
- D Proceed under spinal anaesthesia to avoid airway manipulation
Correct answer: B. Start intravenous fluids, insulin infusion and potassium replacement, then proceed once acidosis is improving and potassium is corrected
Explanation
Emergency surgery in diabetic ketoacidosis warrants a short delay of a few hours for resuscitation, because induction with untreated hypokalaemia and acidosis risks fatal arrhythmia and cardiovascular collapse. Fluids restore perfusion, insulin clears ketones and drives potassium into cells, and potassium must be replaced before levels fall further. Full biochemical resolution is not required before surgery, so waiting for normoglycaemia is excessive. Spinal anaesthesia does not remove the metabolic risk and may be impractical in septic shock.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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Written and medically reviewed by the StethoPrep medical team.