Diabetic ketoacidosis — SCE Endocrinology MCQ

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HardDiabetic emergenciesDiabetic ketoacidosisSCE Endocrinology

A 24-year-old with type 1 diabetes has 12 hours of vomiting, capillary ketones 6.2 mmol/L, venous pH 7.12, bicarbonate 9 mmol/L and glucose 28 mmol/L. Potassium is 4.7 mmol/L. What is the correct initial insulin strategy?

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Correct answer: D — Fixed-rate intravenous insulin with fluids and potassium monitoring

The best answer is “Fixed-rate intravenous insulin with fluids and potassium monitoring”. This is DKA; fixed-rate insulin suppresses ketogenesis while fluids restore perfusion, and potassium is measured repeatedly because insulin and correction of acidosis drive it intracellularly. “Use a variable-rate insulin infusion as the primary ketone-clearance regimen” is less appropriate because variable-rate insulin is used for other inpatient contexts and does not provide the standard weight-based ketone-clearance approach “Give subcutaneous rapid-acting insulin every four hours” is less appropriate because intermittent subcutaneous correction is unreliable in severe acidotic DKA “Give intravenous bicarbonate before insulin because pH is below 7.2” is less appropriate because bicarbonate is not routinely recommended at this pH and can cause harm “Delay insulin until glucose remains above 30 mmol/L after fluids” is less appropriate because ketonaemia and acidosis, not an arbitrary higher glucose threshold, mandate insulin once potassium safety is addressed

Reference: JBDS-IP: The management of diabetic ketoacidosis in adults. https://abcd.care/sites/default/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf