DKA

Question 1

What is diabetic ketoacidosis (DKA)?

Answer 1

A medical emergency caused by insulin deficiency leading to hyperglycaemia, ketosis, and metabolic acidosis.

Question 2

Which patients most commonly develop DKA?

Answer 2

Patients with type 1 diabetes mellitus; it may be the first presentation in ~6% of cases.

Question 3

Can patients with type 2 diabetes develop DKA?

Answer 3

Rarely, usually during extreme physiological stress.

Question 4

What is the current mortality rate of DKA in the UK?

Answer 4

Less than 1%.

Question 5

What is the underlying metabolic process causing DKA?

Answer 5

Uncontrolled lipolysis producing excess free fatty acids that are converted into ketone bodies.

Question 6

Which process is NOT responsible for ketone production in DKA?

Answer 6

Proteolysis.

Question 7

What are the most common precipitating factors for DKA?

Answer 7

Infection, missed insulin doses, and myocardial infarction.

Question 8

What are the key clinical features of DKA?

Answer 8

Abdominal pain, polyuria, polydipsia, dehydration, Kussmaul respiration, and acetone-smelling breath.

Question 9

What causes Kussmaul respiration in DKA?

Answer 9

Compensatory hyperventilation in response to metabolic acidosis.

Question 10

What are the JBDS diagnostic criteria for DKA?

Answer 10

Glucose >11 mmol/L or known diabetes, pH <7.3, bicarbonate <15 mmol/L, and ketones >3 mmol/L or urine ketones ++.

Question 11

What is the key difference between ADA and JBDS glucose thresholds?

Answer 11

ADA uses >13.8 mmol/L, JBDS uses >11 mmol/L or known diabetes.

Question 12

What are the three main principles of DKA management?

Answer 12

Fluid replacement, insulin therapy, and correction of electrolyte disturbance.

Question 13

How much fluid deficit is typical in DKA?

Answer 13

Approximately 5–8 litres.

Question 14

What is the initial fluid of choice in DKA?

Answer 14

0.9% sodium chloride, even if the patient is severely acidotic.

Question 15

What insulin regimen is used in DKA?

Answer 15

Fixed-rate intravenous insulin infusion at 0.1 units/kg/hour.

Question 16

When should dextrose be added to fluids in DKA?

Answer 16

When blood glucose falls below 14 mmol/L.

Question 17

What dextrose infusion is used once glucose is <14 mmol/L?

Answer 17

10% dextrose at 125 mL/hour alongside saline and insulin.

Question 18

What happens to potassium levels in DKA?

Answer 18

Serum potassium may be high initially despite total body potassium depletion.

Question 19

Why does hypokalaemia commonly occur during treatment?

Answer 19

Insulin drives potassium into cells, rapidly lowering serum potassium.

Question 20

When is cardiac monitoring required during potassium replacement?

Answer 20

If potassium infusion exceeds 20 mmol/hour.

Question 21

According to JBDS, how is potassium replaced if K⁺ is 3.5–5.5 mmol/L?

Answer 21

Add 40 mmol potassium to each litre of infusion fluid.

Question 22

What should be done if potassium is <3.5 mmol/L?

Answer 22

Urgent senior review and additional potassium replacement.

Question 23

Should long-acting insulin be stopped during DKA treatment?

Answer 23

No, long-acting insulin should be continued.

Question 24

What should be stopped during IV insulin therapy?

Answer 24

Short-acting subcutaneous insulin.

Question 25

How is resolution of DKA defined?

Answer 25

pH >7.3, blood ketones <0.6 mmol/L, and bicarbonate >15 mmol/L.

Question 26

Within what time frame should ketosis and acidosis resolve?

Answer 26

Within 24 hours.

Question 27

What should be done if DKA has not resolved by 24 hours?

Answer 27

Urgent senior endocrinology review.

Question 28

When can a patient be switched back to subcutaneous insulin?

Answer 28

When DKA has resolved and the patient is eating and drinking.

Question 29

Who should review the patient before discharge?

Answer 29

The diabetes specialist nurse.

Question 30

What are key complications of DKA itself?

Answer 30

Gastric stasis, thromboembolism, arrhythmias, AKI, and ARDS.

Question 31

What are key treatment-related complications of DKA?

Answer 31

Hypoglycaemia, hypokalaemia, and cerebral oedema.

Question 32

Which group is at highest risk of cerebral oedema?

Answer 32

Children and young adults (18–25 years).

Question 33

When does cerebral oedema most commonly occur?

Answer 33

4–12 hours after starting treatment, but it can occur at any time.

Question 34

What symptoms suggest cerebral oedema in DKA?

Answer 34

Headache, irritability, visual disturbance, reduced consciousness, or focal neurology.

Question 35

What should be done if cerebral oedema is suspected?

Answer 35

Urgent senior review and CT head.