Outline the initial management steps for DKA, including fluids and when to start insulin therapy.

• A. Begin isotonic saline; start insulin immediately without potassium check; add dextrose when glucose falls below 100.
• B. Begin isotonic saline; once potassium is checked and potassium ≥3.3, start IV regular insulin; continue fluids; add dextrose when glucose around 200 mg/dL.
• C. Start dextrose infusion; avoid fluids; insulin only after 24 hours.
• D. Begin hypotonic fluids; never give insulin in DKA.

Answer: (B)

Initial DKA management focuses on restoring intravascular volume, correcting electrolyte disturbances, and safely initiating insulin. Begin with isotonic saline to rapidly replenish fluids and improve perfusion, since dehydration and poor circulating volume are immediate threats. You typically start with a large fluid bolus and then continue with ongoing IV fluids while monitoring blood pressure, urine output, and electrolyte status.

Potassium is a critical early consideration. Although the serum potassium level may be normal or high at presentation, total body potassium is depleted from urinary losses during the DKA state. Because insulin administration drives potassium into cells, starting insulin before potassium is adequately corrected can precipitate dangerous hypokalemia. Therefore, insulin is started only after confirming potassium is at least 3.3 mEq/L. If potassium is below 3.3, you hold insulin and aggressively replace potassium until it rises above that threshold, then begin insulin while continuing to monitor and replete potassium as needed. Once potassium is safe to proceed, you start IV regular insulin and continue fluids.

Dextrose is added when blood glucose approaches around 200 mg/dL. This prevents hypoglycemia as insulin therapy continues to correct the acidosis and hyperglycemia, while allowing ongoing insulin-driven clearance of ketones. At that point, you switch to a dextrose-containing fluid while maintaining the insulin infusion.

Throughout, you keep close track of electrolytes, bicarbonate, glucose, and fluid status, adjusting as labs and clinical signs guide you.