Internal Medicine Exam Diabetic Ketoacidosis Management 3 — Questions and Answers
Question 1: A patient in DKA is started on a normal saline infusion. After 2 liters, serum chloride is 112 mEq/L. What complication is developing?
- Hyperkalemia from saline load
- Hyperchloremic non-anion gap metabolic acidosis (Correct answer)
- Dilutional hyponatremia
- Iatrogenic metabolic alkalosis
Correct answer: Hyperchloremic non-anion gap metabolic acidosis
Large volumes of normal saline can cause hyperchloremic non-anion gap metabolic acidosis, which may obscure DKA resolution.
Question 2: Which ketone body is predominantly elevated in DKA but NOT detected by the nitroprusside urine ketone test?
- Acetoacetate
- Acetone
- Beta-hydroxybutyrate (Correct answer)
- Pyruvate
Correct answer: Beta-hydroxybutyrate
Beta-hydroxybutyrate is the predominant ketone in DKA but is not detected by nitroprusside-based urine/serum ketone tests.
Question 3: A 45-year-old with type 2 diabetes on an SGLT-2 inhibitor presents with glucose of 210 mg/dL, pH 7.21, and elevated ketones. What is this presentation called?
- Hyperosmolar hyperglycemic state
- Euglycemic DKA (Correct answer)
- Lactic acidosis
- Starvation ketosis
Correct answer: Euglycemic DKA
SGLT-2 inhibitors can cause euglycemic DKA — elevated ketones and metabolic acidosis with near-normal blood glucose.
Question 4: What is the recommended initial fluid bolus for an adult presenting in DKA with moderate dehydration?
- 500 mL 0.45% NaCl over 4 hours
- 1 liter 0.9% NaCl over 1 hour (Correct answer)
- 1 liter D5W over 1 hour
- 250 mL colloid solution over 30 minutes
Correct answer: 1 liter 0.9% NaCl over 1 hour
Initial resuscitation in DKA uses 1 L of isotonic (0.9%) normal saline over the first hour.
Question 5: In DKA management, when is sodium bicarbonate administration currently recommended by most guidelines?
- pH < 7.30
- pH < 7.20
- pH < 7.10 with hemodynamic instability or severe hyperkalemia (Correct answer)
- All DKA patients to speed resolution
Correct answer: pH < 7.10 with hemodynamic instability or severe hyperkalemia
Sodium bicarbonate is generally reserved for severe acidosis (pH <7.0–7.1) complicated by hemodynamic compromise or life-threatening hyperkalemia.
Question 6: A child with DKA develops a sudden headache and altered mental status 6 hours into treatment. What is the most feared complication?
- Hypokalemia-induced arrhythmia
- Cerebral edema (Correct answer)
- Hyperchloremic acidosis
- Aspiration pneumonia
Correct answer: Cerebral edema
Cerebral edema is a rare but potentially fatal complication of DKA in children, often occurring 6–12 hours into treatment.
Question 7: Which insulin regimen is standard for inpatient DKA management in adults?
- Subcutaneous rapid-acting insulin every 6 hours
- Continuous IV regular insulin infusion at 0.1 units/kg/hr (Correct answer)
- Subcutaneous insulin glargine once daily
- IM regular insulin every 4 hours
Correct answer: Continuous IV regular insulin infusion at 0.1 units/kg/hr
Continuous IV regular insulin at 0.1 units/kg/hr (after potassium is replete) is the standard of care for adult DKA.
Internal Medicine Exam Diabetic Ketoacidosis Management 3
A patient in DKA is started on a normal saline infusion.
After 2 liters, serum chloride is 112 mEq/L.
What complication is developing?