What is the most appropriate initial intervention for a patient with diabetic ketoacidosis presenting with a blood glucose of 650 mg/dL?

In the scenario of a patient with diabetic ketoacidosis (DKA) presenting with a significantly elevated blood glucose level of 650 mg/dL, the most appropriate initial intervention is to ensure that serum potassium levels are adequate before starting an insulin infusion.

In DKA, patients often experience metabolic derangements, including changes in potassium levels. Even if initial potassium levels are normal or high, insulin therapy can cause a shift of potassium into the cells, potentially leading to hypokalemia, which can complicate the clinical picture and cause serious cardiac issues. Therefore, it is crucial to first check the serum potassium level and ensure it is above 3.3 mmol/L before administering insulin. If the potassium is low, appropriate potassium repletion is necessary to avoid life-threatening complications.

Once the potassium levels are confirmed to be above the threshold, insulin therapy can be initiated to address the hyperglycemia and ketonemia associated with DKA. This sequential approach assures both the safety of the patient and the effectiveness of the treatment. Thus, focusing on potassium repletion prior to starting insulin is essential in the management of a patient with DKA.