In DKA, how is potassium typically altered and how should it be managed?

• A. Total body potassium is depleted despite normal to high serum potassium; hold insulin if K+ <3.3 mEq/L, replete potassium to around 4–5 mEq/L, restart insulin when K+ ≥3.3
• B. Total body potassium is elevated; never replete potassium
• C. Total body potassium is unaffected; always start insulin
• D. Total body potassium is depleted with serum potassium always low; do not restart insulin until K+ >5

Answer: (A)

In DKA the body is potassium-depleted overall, even though the blood potassium level can appear normal or high. This happens because a lack of insulin and acidosis push potassium out of cells, while osmotic diuresis and vomiting cause renal potassium loss. The treatment plan must account for this shift: insulin therapy will drive potassium back into cells and can cause dangerous hypokalemia if potassium is not replenished first or monitored closely.

If the serum potassium is below 3.3 mEq/L, insulin should be withheld and potassium given until the level rises to at least 3.3; only then should insulin be restarted. If the potassium is between about 3.3 and 5.0, insulin can be started and potassium should be given to keep the serum potassium around 4–5 mEq/L. If potassium is greater than 5, insulin can be started but you would monitor potassium carefully and avoid aggressive potassium supplementation unless it begins to fall. This approach prevents dangerous shifts as treatment reverses the potassium imbalance.