New-onset DKA in a district hospital — OSCE

Task

You have twelve minutes. Confirm the diagnosis and severity, begin the ISPAD-aligned management appropriate to a district hospital, decide about retrieval, set up the monitoring that will catch deterioration, and explain the situation to the parents with clarity and compassion. The examiner will assess both your clinical plan and your communication. [1]

Confirming the diagnosis and severity

State the diagnosis clearly: this is diabetic ketoacidosis, almost certainly new-onset type 1 diabetes, confirmed by the triad of a very high glucose, blood ketones of 6.1 mmol/L, and a venous pH of 7.12 with a bicarbonate of 8 mmol/L. By the pH and bicarbonate this is moderate DKA, bordering on severe, and she is dehydrated but not shocked. Weigh her, document a baseline Glasgow Coma Scale, and set up hourly observations from the start. [1]

Beginning management before retrieval

Begin the ISPAD protocol without waiting for transfer. Because she is not shocked, she does not need a fluid bolus; start steady rehydration with isotonic saline giving maintenance plus a modest deficit spread evenly over 48 hours, and add potassium at 40 mmol/L once her potassium is below 5.5 mmol/L and she has passed urine. Start insulin only after fluids are running, an hour or two in, as a continuous infusion of 0.05 to 0.1 units/kg/h, never as a bolus, and add 5 per cent dextrose once her glucose falls below roughly 14 to 17 mmol/L so the insulin can keep clearing the ketones. [1] [8]

Deciding on retrieval and monitoring

Moderate-to-severe DKA in a nine-year-old at a hospital without paediatric intensive care warrants an early call to the retrieval service, so that transfer can be arranged while you stabilise her. Do not delay starting treatment for the transfer. The monitoring that matters is hourly: neurological observations and conscious level, vital signs, glucose and ketones, with electrolytes and a gas every one to two hours. The single most important thing you are watching for is cerebral oedema — a headache, a falling conscious level, or a rising blood pressure with a slowing heart rate — which you would treat immediately with hypertonic saline or mannitol and a reduced fluid rate, on clinical grounds, without waiting for a scan. [3] [9]

Explaining the diagnosis to the parents

Sit with the parents and be direct but gentle. Explain that their daughter has diabetes — her body has stopped making insulin, the hormone that lets her use sugar for energy — and that this has made her seriously unwell with a condition called diabetic ketoacidosis, which you are now treating. Reassure them that this is a recognised way for diabetes to first show itself, that it is not anyone's fault, and that with careful treatment most children recover fully. Acknowledge the shock of a diagnosis they did not expect, and give them space to ask questions. [1]

Setting expectations and next steps

Tell them the plan in plain terms: fluids and insulin given slowly and carefully over the next day or two, close monitoring, and transfer to a children's intensive care unit where the specialist diabetes team will take over. Explain that once she is better she and the family will learn how to manage diabetes with insulin injections, glucose checks, and a plan for sick days, and that they will be supported through all of it. Be honest that the treatment is deliberately slow to protect her brain, and that this is why she is watched so closely. Finish by checking what they have understood and answering their questions. [1] [8]