St Emlyn’s Lesson Plans

DKA: treat the patient and follow the trend

Work through the adult DKA pathway and discuss what to check when treatment is not producing the expected improvement.

Early-career Emergency Medicine · 45-minute session

For learners

Before: Allow about 18 minutes in total.

When we meet: We will discuss the first hour of DKA care, falling potassium and persistent acidosis during treatment.

After: choose a point to follow up in practice

For facilitators

Send: the learner preparation link before teaching.

Bring: Approved local adult DKA treatment chart, the fictional trend table supplied here, calculator, and a whiteboard. A pump/tubing photograph is optional.

Run: 45-minute session plan · 30-minute option

Before the session

If you are attending this session, complete the core preparation below before you come. Allow about 18 minutes in total.

Core preparation

JBDS 02: Management of DKA in adults · About 15 minutes

Read the single-page adult pathway on printed page 9 and the potassium, response-monitoring and resolution sections on printed pages 27–30. The facilitator will bring the approved local chart.

https://abcd.care/sites/default/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf

Think about (allow 3 minutes): What would you check if glucose was falling but ketones and acidosis were not improving?

Picture the scene

A young adult with type 1 diabetes has vomiting, abdominal pain and deep rapid breathing. Glucose is high. What else do you need for the first-hour plan?

By the end of the session

Recognise ketoacidosis using ketones, acid-base status and the clinical context rather than glucose alone.
Explain the coordinated roles of fluid, insulin, potassium and close monitoring.
Recognise failure to improve and distinguish persistent ketosis from additional causes of acidosis.

After the session

On your next DKA handover, name the next biochemical checkpoint and the clinician responsible for acting on it.

Facilitator guide

Send learners the preparation link several days before teaching. Allow about 18 minutes in total.

Before learners arrive

Check the current local adult DKA chart with diabetes staff, including potassium, reduced insulin rate as glucose falls, basal insulin and transition instructions.
Review the supplied fictional trend exercise with the local diabetes team before teaching and check its discussion notes. This is an adult session; agree where the local paediatric/adolescent pathway applies.

Equipment: Approved local adult DKA treatment chart, the fictional trend table supplied here, calculator, and a whiteboard. A pump/tubing photograph is optional.

Setup: Small groups work around a single chart. Ask one person to prescribe, another to check and another to describe the nursing workload and monitoring feasibility.

If the preparation has not been completed

Replace the five-minute opening with the JBDS/local adult DKA pathway. Give the group two minutes to read, with each person locating either fluid, insulin or monitoring responsibilities, then use three minutes to explain how the tasks depend on one another. Keep the chart open and use the supplied trend table later. In the 30-minute plan, use five minutes here and reduce the first-hour chart exercise from 12 to 10 minutes.

Suggested session plan

0–5 min — Recognise the syndrome. Ask what is missing if the handover contains only a glucose value.
5–20 min — Coordinate the first hour. Work through the chart and make monitoring ownership explicit.
20–35 min — Troubleshoot the trend. Reveal the supplied table one row at a time. Compare the ketone change with the pathway and explain the falling-potassium concern before discussing the separate acidosis variation.
35–40 min — Precipitant conversation. Practise a non-blaming enquiry about insulin access or pump problems.
40–45 min — Close. Each learner states what they would need before stopping IV insulin.

Start the discussion

Read the opening scenario together. Give everyone a moment to think, then ask what concerns them and what they need to know next.

Cases and discussion

Use these cases, or invite an anonymised case from the group that addresses the same questions.

A first hour that needs coordination

A 21-year-old with type 1 diabetes has vomiting and abdominal pain. Pulse is 122, BP 110/71 and respiratory rate 34. Glucose is 25 mmol/L, blood ketones 5.2 mmol/L and venous pH 7.12. Potassium is 5.8 mmol/L.

Add this information as the discussion develops:

Ask learners to identify the acid-base problem and the additional assessment needed.
A friend says the insulin pump has repeatedly alarmed. The patient is worried about being blamed.
After treatment begins, glucose is falling but potassium is also falling. Ask which measurements and prescriptions need review.

Ask the group:

Which results establish ketoacidosis, and which describe severity?
What could be the precipitant besides infection?
Why can serum potassium be high while total-body potassium is depleted?
Who will check the infusion is actually reaching the patient?

Discussion notes

Points to draw out:

Use the current JBDS criteria and pathway. Acidosis includes bicarbonate below 15 mmol/L and/or venous pH below 7.3. Assess ketones and the full context, including known diabetes.
Fluids, fixed-rate insulin, potassium and monitoring are interdependent. Use the approved chart, continue appropriate basal insulin and reassess physiology and biochemical response. Severe or ECG-associated hyperkalaemia needs urgent senior management; do not assume DKA treatment makes every potassium result safe.
Ask about pump function, access to insulin, illness, pregnancy where relevant and medicines without using judgemental language. A practical precipitant may be fixable before discharge.

Common misconceptions:

Treating glucose as the only target.
Assuming a written infusion prescription proves delivery.
Calling compensatory low carbon dioxide a separate primary respiratory alkalosis without checking whether compensation is appropriate.

For a more experienced group: Ask the group to make an explicit first-hour task allocation and a handover naming the next tests and who will respond.

The numbers are not moving together

Use the four-hour row in the supplied fictional trend exercise: glucose is 12 mmol/L, ketones 4.6 mmol/L, venous pH 7.18 and potassium 3.4 mmol/L. A colleague wants to stop the DKA treatment because glucose has improved. What needs review now?

Add this information as the discussion develops:

Show the readings one row at a time. Ask when the ketone response first requires review, what is happening to potassium and what must be checked at the bedside.
After the trend discussion, consider a separate variation in which ketones have cleared but acidaemia persists and chloride has risen. Ask what further assessment is needed; do not assume chloride is the only possible explanation.
A further variation is a patient taking an SGLT2 inhibitor with vomiting, acidosis and only modest hyperglycaemia.

Ask the group:

What would convince you DKA had resolved?
Why might glucose need to be given while insulin continues?
What distinguishes failure of treatment delivery from a changing type of acidosis?
When is more senior or critical-care support needed?

Discussion notes

Points to draw out:

Resolution is not defined by glucose alone. Use ketone and pH criteria and the current pathway for glucose supplementation, insulin adjustment and safe transition.
In the supplied exercise, the slow ketone fall requires review from the first hour. Potassium 3.4 mmol/L at four hours needs urgent senior assessment and the local potassium/insulin plan; do not respond to slow ketone clearance by increasing insulin automatically.
Persistent acidosis may have more than one cause. Reassess the patient and treatment delivery before attributing everything to fluid chloride or increasing insulin reflexively.
SGLT2-associated ketoacidosis can occur with near-normal glucose. Check blood ketones when the clinical picture suggests it, stop the implicated medicine if DKA is suspected and obtain specialist input.

Common misconceptions:

Stopping insulin while clinically important ketosis persists.
Debating balanced fluids while failing to notice a disconnected infusion.

For a more experienced group: For the separate ketone-cleared variation, ask which additional findings would support another cause of acidosis and what still needs to be met before a safe transition.

DKA trend exercise: glucose improves before the whole problem resolves

These fictional results continue the first case. They are selected readings from an adult receiving DKA treatment, not a complete monitoring chart. Compare each new result with the patient, treatment record and current local pathway.

Time from treatment start	Glucose (mmol/L)	Blood ketones (mmol/L)	Venous pH	Potassium (mmol/L)
0 hours	25	5.2	7.12	5.8
1 hour	21	4.9	7.15	4.7
2 hours	17	4.8	7.17	4.0
4 hours	12	4.6	7.18	3.4

Calculate the ketone fall per hour in each interval. At which point would you first question the response?
Which bedside, infusion-delivery and prescription checks would you make before changing treatment?
What makes the four-hour potassium result urgent, even though glucose has improved?
What would need to change before you could say the ketoacidosis had resolved?

Worked discussion notes

For the facilitator: ketones fall by 0.3 mmol/L in the first hour, 0.1 in the second and 0.2 over the next two hours. Response already needs review after the first interval; do not wait until four hours.
JBDS expects a ketone fall of at least 0.5 mmol/L per hour. Reassess the person and check infusion delivery, fluid balance, medicines and the current treatment chart.
Potassium 3.4 mmol/L needs urgent senior review and the local replacement/insulin plan. An automatic insulin increase could worsen hypokalaemia.
Glucose 12 mmol/L does not establish resolution. Use the current pathway for glucose support and insulin adjustment; the JBDS resolution criteria use blood ketones below 0.6 mmol/L and venous pH above 7.3.
These invented readings are not dosing instructions or a monitoring schedule. Check the exercise with the local diabetes team before teaching; clinical review is pending.

Fictional teaching exercise. The added values and worked notes await clinical review before use.

Important clinical points

Use the current DKA pathway, including the correct acidosis criteria and monitoring requirements.
Do not transfer adult fluid or insulin instructions to children.
Severe potassium abnormalities, neurological deterioration or shock require urgent senior assessment.

Closing the session

Use these questions to check what the group will take away. Go back over any clinical points that remain unclear.

Why may insulin need to continue as glucose falls?
What would you check before declaring treatment failure?
Which results define resolution in the current pathway?

Key teaching points:

Follow ketones, acid-base status, potassium and the clinical response as well as glucose.
If progress is poor, check the patient, infusion delivery and prescriptions before changing treatment.
Ask about the precipitant and practical difficulties with insulin so these can be addressed before discharge.

Before leaving, ask each person to choose one action from After the session and say when they will try it. They complete that follow-up in practice, with supervision where needed.

Adapting the discussion

Uncertainty and local practice

Fluid choice can be debated, but local approved practice and safe potassium delivery matter. Do not present balanced crystalloid superiority or a single chloride explanation as settled for every patient.

If the discussion drifts

What is not improving, what have you checked at the bedside, and what will you change safely?

For a more experienced group

Explore mixed acid-base disturbances, renal/cardiac comorbidity and escalation while preserving the basic monitoring sequence.

A 30-minute version

30-minute option: diagnosis 3, first-hour chart 12, trend case 10, closing 5. Omit fluid-comparison debate.

Evidence and guidance

JBDS 02: Management of DKA in adults — March 2023 adult guideline and the accompanying single-page treatment pathway.https://abcd.care/resource/current/jbds-02-management-diabetic-ketoacidosis-adults
MHRA: SGLT2 inhibitors and ketoacidosis — Medicine safety warning: assess ketones even with near-normal glucose when symptoms suggest ketoacidosis.https://www.gov.uk/drug-safety-update/sglt2-inhibitors-updated-advice-on-the-risk-of-diabetic-ketoacidosis
JBDS adult DKA guideline: monitoring and treatment response — March 2023, printed pages 27–30: potassium review, ketone response, infusion checks and resolution. The accompanying teaching table contains invented values and needs local clinical review.https://abcd.care/sites/default/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf