A 9-year-old with known type 1 diabetes presents with vomiting, Kussmaul breathing, blood glucose 420 mg/dL, and venous pH 7.12. Insulin infusion is started. After 2 hours the serum potassium drops to 2.8 mEq/L. What is the correct action?

• A Continue insulin infusion; add potassium to IV fluids at 40 mEq/L
• B Stop insulin and replace potassium orally
• C Increase insulin rate to clear ketosis faster
• D Hold insulin infusion and give IV potassium chloride 0.3 mEq/kg/hr ✓

Explanation

In pediatric DKA, insulin should be withheld when serum potassium falls below 3.0 mEq/L and IV potassium replacement (not to exceed 0.3–0.5 mEq/kg/hr) should be given until potassium is ≥3.5 mEq/L before resuming insulin. Continuing insulin in severe hypokalaemia risks life-threatening cardiac arrhythmia. Oral replacement is insufficient in acute severe DKA. Increasing insulin worsens hypokalaemia by driving potassium intracellularly.

Reference: Ghai Essential Pediatrics, 10th ed.

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Written and medically reviewed by the StethoPrep medical team.