Which of the following combinations of adverse effects must be carefully monitored when administering I.V. insulin to a patient diagnosed with diabetic ketoacidosis?

1. A

   Hypercalcemia and hypernatremia

2. B

   Hypokalemia and hypoglycemia

3. C

   Hypocalcemia and hyponatremia

4. D

   Hyperkalemia and hyperglycemia

Appeared in: JODHPUR AIIMS SNO-2018

Explanation

• IV insulin is a cornerstone of DKA treatment, but it can cause significant and rapid shifts in electrolytes and glucose.
• Insulin facilitates the uptake of glucose into cells, which lowers blood sugar. If not carefully managed, this can lead to hypoglycemia (low blood sugar), a dangerous complication.
• Insulin also activates the Na⁺-K⁺-ATPase pump, driving potassium from the bloodstream into the cells. This causes a rapid drop in serum potassium levels (hypokalemia).
• Severe hypokalemia can lead to life-threatening cardiac arrhythmias, muscle weakness, and respiratory failure. Therefore, both glucose and potassium must be monitored closely during IV insulin therapy for DKA.

Why Other Options Were Wrong

• Option A: Insulin therapy does not cause high calcium (hypercalcemia) or high sodium (hypernatremia).
• Option C: Insulin does not directly cause low calcium (hypocalcemia). While initial DKA presentations can involve hyponatremia due to osmotic shifts, insulin therapy helps correct this, it doesn't cause it as an adverse effect.
• Option D: Hyperkalemia (high potassium) and hyperglycemia (high blood sugar) are the initial problems that define DKA and are what insulin is used to treat.

Related Visual

Clinical Relevance

• Nursing practice connection: Use the key finding related to Monitoring for adverse effects of IV insulin therapy in Diabetic Ketoacidosis (DKA) to guide bedside assessment, documentation, and the next nursing action.
• In DKA management, nurses must perform hourly bedside glucose monitoring and frequent electrolyte checks (especially potassium) as per hospital protocol.
• A 'sliding scale' insulin protocol is often used, but it must be paired with a continuous IV dextrose infusion (e.g., D5W) once blood glucose falls to a certain level (e.g., below 250 mg/dL) to prevent hypoglycemia while continuing to treat the ketosis.
• What if? If a patient in DKA has a normal or low initial potassium level (e.g., 3.3 mEq/L), insulin therapy should be delayed, and potassium replacement should be started first. Starting insulin would cause a further dangerous drop in potassium.

How to Approach the Question

• Identify the core clinical scenario: treating Diabetic Ketoacidosis (DKA) with IV insulin.
• Recall the primary physiological actions of insulin. It moves glucose AND potassium from the blood into cells.
• Translate these actions into potential adverse effects. Moving glucose into cells causes blood glucose to drop (risk of hypoglycemia). Moving potassium into cells causes blood potassium to drop (risk of hypokalemia).
• Evaluate the options based on this understanding. 'Hypokalemia and hypoglycemia' directly matches the known major risks of insulin therapy.
• Eliminate other options. Hyperglycemia and hyperkalemia are the problems being treated, not the side effects. Calcium and sodium are less directly and critically affected by insulin itself.

Concept Tested & Keywords

• Concept Tested: Monitoring for adverse effects of IV insulin therapy in Diabetic Ketoacidosis (DKA).
• Stem keywords: I.V. insulin, diabetic ketoacidosis, adverse effects, monitor
• Lead-in keywords: Which of the following
• Negative lead-in flag: false

Question ID

QN4UcoJhZZH8vGVLCbHIh5

Copy ID

Reference Book

E6 Ghai Essential Pediatrics(pp 26-904 of 913) p. 568-570

E6 Medicine Davidson Principles Practice 24e p. 756-758