A fictional 32-year-old with type 1 diabetes is receiving protocol treatment for DKA. Glucose has fallen substantially, but ketones remain elevated and bicarbonate remains low.
Listen for the assumption.
The glucose is near target, so I was preparing to stop the fixed-rate insulin infusion.
Which biochemical process are we actually trying to stop?
Ketogenesis. We need to continue protocol-directed insulin, add glucose when indicated and monitor ketones, acidosis and potassium until resolution criteria are met.
Choose an answer below and reveal the reasoning to see consultant feedback at every checkpoint. The full consultant-led synthesis follows after all three decisions.
Go to the first decision ↓The picture develops.
- Blood ketones remain elevated
- Venous bicarbonate remains low
- Potassium is falling during treatment
Commit before you reveal.
After you select an option, reveal the model reasoning and the consultant’s feedback.
Hear the senior team refine the plan.
The registrar tests the plan, the consultant synthesises the key principle, and the SHO confirms the safer next steps.
I want hourly metabolic targets, fluid balance and a trigger for senior review if improvement is inadequate.
Also identify the precipitant, confirm basal insulin continuity where appropriate and plan the transition from intravenous insulin safely.
I will hand over ketone, bicarbonate, glucose and potassium trends—not simply that the glucose has improved.
What must remain explicit.
- Use the current JBDS and local adult DKA protocol.
- Monitor potassium, glucose, ketones, acid-base status and fluid balance at protocol intervals.
- Escalate inadequate biochemical improvement, hypokalaemia, hypoglycaemia or neurological deterioration.
Where reasoning fails.
- Stopping insulin when glucose normalises
- Failing to track ketones and bicarbonate
- Overlooking the precipitating illness
DKA treatment started [time]; glucose [trend], ketones [trend], bicarbonate/pH [trend], potassium [trend/replacement], fluids [balance] and precipitant [status]. Resolution criteria are [met/not met].
Which four trends would you insist on seeing before accepting a DKA handover?