In DKA management, which fluid regimen is typically initiated?

• A. Dextrose-containing fluids first
• B. Oral fluids only
• C. No fluids until labs
• D. Normal saline first, then IV regular insulin, fingerstick glucose

Answer: (D)

In DKA, the most urgent need is to restore intravascular volume and perfusion first. Patients are severely dehydrated from osmotic diuresis and often present with poor skin turgor, tachycardia, and orthostatic changes. Starting with isotonic IV fluids, typically normal saline, replenishes circulating volume, improves renal perfusion, and begins correcting electrolyte disturbances. After the patient is adequately rehydrated, insulin is started to stop ketone production, reduce blood glucose, and resolve acidosis.

Monitoring is essential, so glucose is checked frequently with fingerstick testing to guide therapy and to determine when to switch fluids to a dextrose-containing solution (usually when glucose drops to about 200 mg/dL) to prevent hypoglycemia while continuing to correct the metabolic derangements. Potassium shifts are a critical consideration because insulin drives potassium into cells, so potassium levels are monitored and corrected as needed during treatment. The described approach—normal saline first, then IV regular insulin, with close glucose monitoring—is the appropriate sequence for managing DKA.