Fever and generally unwell- DKA

Question

35-year-old woman with poorly controlled type 1 diabetes mellitus comes into the hospital with abdominal pains and fevers. Kindly assess the patient and proceed.

Answer

I will start by getting a focused history from the patient to understand the onset of symptoms and other systemic symptoms she has. I would specifically do a systems review looking at infectious symptoms. I would also enquire about her type 1 diabetes control and compliance with insulin. Additionally, I would ask about her history of previous hospital admissions and any diabetic complications.

I would also explore her social circumstances and family history. After completing the history, I would perform a focused A to E assessment:

A to E Assessment

• Airway: Ensure the airway is patent and, if necessary, insert an airway adjunct such as OP or NP airway. If the patient requires an airway adjunct, escalate the case to the critical care team.
• Breathing: Assess oxygen saturation and respiratory rate. Administer supplemental oxygen therapy if hypoxic or if there is increased work of breathing. Request a PEFR and ABG to evaluate pH, PO₂, PCO₂, HCO₃, and lactate levels. A portable chest X-ray may be arranged if respiratory concerns arise.
• Circulation: Evaluate BP, heart rate, and CRT. If there is evidence of hypotension or tachycardia, provide fluid resuscitation to assess the response. Insert a working cannula and send blood for septic screening and basic labs. An ECG may also be warranted.
• Disability: Check blood glucose, capillary ketones, temperature, and conduct a focused neurological assessment, including GCS. Escalate concerns if GCS <8 or there are focal neurological deficits.
• Exposure: Perform an abdominal examination to rule out intra-abdominal pathology and look for signs of subcutaneous or cutaneous infection.

Additional Question

At this point, interrupt the candidate and provide the following information: The patient has had two admissions in the past with DKA due to poor compliance. She mentions she has been compliant with insulin therapy. Recently, she visited her sister’s children, who were unwell with the flu. On examination, she has decreased air entry at the right lung base with right basal crackles. ABG results: pH 7.2, PO₂ 12, PCO₂ 4, HCO₃ 14, Lactate 2.0, potassium 3.2. Capillary ketones are 3.3. How would you proceed?

Answer

Based on the clinical evidence, I suspect the patient has DKA secondary to right-sided pneumonia. The ABG shows severe metabolic acidosis, and the elevated capillary ketones confirm DKA.

• Start treatment for DKA with IV fluids to replace losses (1–1.5L in the first hour based on BP) and initiate IV insulin therapy at 0.1 mL/kg/hour, as per local DKA protocol.
• Monitor capillary glucose and ketones hourly and venous bicarbonate and pH at baseline, then every two hours. Electrolytes, especially potassium, should be checked every four hours, with prompt replacement as needed.
• Continue the patient’s long-acting insulin as prescribed.
• Begin antibiotics for suspected pneumonia and send blood cultures and sputum samples for microbiological analysis.
• Monitor the patient in a high-dependency unit (HDU) for at least 12–24 hours. Escalate care to ICU if necessary, particularly if markers such as SpO₂, GCS, or pH deteriorate.

Question

What would indicate the DKA is resolving?

Answer

Resolution of DKA is indicated by:

• pH > 7.3
• Capillary ketones < 0.6

If the patient cannot eat or drink, switch to a variable rate insulin infusion. If the patient can eat and drink, transition to regular subcutaneous short-acting insulin. Arrange a diabetic specialist review before discharge.