You notice the patient is showing signs of shock (raised pulse, low blood pressure). Given the context of DKA, this is probably hypovolemic shock.

You remember the general principle in medicine that as the patient gets more sick, the treatment gets more basic. You go back to the ABCs, and realise a fluid challenge and reassessment is the best approach to any cause of raised pulse and low blood pressure without any fluid overload features. The patient’s observations improve.

You now remember that insulin can cause fluid to shift from the extracellular space (which includes the vascular space) to the intracellular space. Now that the insulin is running, you decide to put up fluids in accordance with the Diabetes UK guidance:

A 2nd year medical student on a surgical firm then appears from under the patient bed. It turns out he had been there for twelve days because this same bed had been used in the theatre recovery ward, and the student was too nervous to ask his consultant if he could go home after the last operation. Despite his malnourished state, the student is inquisitive and asks how you are going to tell if the DKA is resolving. You smile like Prince Sidon:

and then confidently reply:

Resolution is defined as ketones <0.3 mmol/L and venous pH>7.3

The 2nd year student’s eyes start twitching as he stares at you. He then slowly sings: “ketones less than point three, tee hee, tee hee, pH less than seven point three, then I am free!”. You make a welfare referral for this student.

Score: 5/10 – although the patient survived, remember that fluids are given before insulin in DKA to avoid circulatory collapse when insulin causes an intracellular shift of fluid, glucose and potassium. The ABG was also necessary pain compared to a VBG.