During DKA treatment, if potassium is less than 3.3 mEq/L, what is the recommended action?

• A. Delay insulin and give potassium
• B. Start insulin immediately and give potassium anyway
• C. Do not give potassium and wait
• D. Increase fluids only

Answer: (A)

Potassium management is the crucial issue when treating DKA. In DKA, total body potassium is typically depleted from potassium losses, even if the blood potassium looks normal or high. However, insulin therapy and correction of acidosis cause potassium to shift back into cells. If potassium is very low, starting insulin would push potassium into cells too quickly, risking life-threatening hypokalemia and dangerous heart rhythms.

When the serum potassium is below 3.3 mEq/L, the priority is to correct potassium first. Give potassium replacement (usually IV potassium) to raise the level above 3.3, then begin insulin therapy while continuing potassium monitoring and replacement to keep potassium in a safe range. This approach protects the heart and allows effective glucose and acidosis correction once potassium is stabilized.

Delaying potassium or trying to treat with fluids alone would not address the immediate risk of hypokalemia once insulin is started, and could lead to arrhythmias.