In DKA, fluid management as glucose falls?

• A. Start with LR; switch to 0.9% NaCl when glucose ~200 mg/dL.
• B. Start with 0.45% NaCl; switch to 0.9% NaCl when glucose ~200 mg/dL.
• C. Start with 0.9% NaCl; switch to 0.45% NaCl when hemodynamically stable and glucose ~200 mg/dL; add dextrose to fluids when glucose approaches 200 mg/dL.
• D. Start with 0.9% NaCl; never add dextrose regardless of glucose.

Answer: (C)

In DKA, fluid therapy is about supporting perfusion early and then adjusting as glucose falls while you continue insulin to clear ketones. Start with a large volume of isotonic saline (0.9% NaCl) to restore intravascular volume. When the patient is hemodynamically stable and the glucose has fallen to around 200 mg/dL, switch to a more isotonic-balanced fluid like 0.45% NaCl to avoid overloading with sodium and to match ongoing volume needs. At that point, start adding dextrose to the IV fluids so you can continue the insulin infusion to complete ketosis and acidosis resolution without letting glucose drop too low. This combination—initiate with 0.9% NaCl, transition to 0.45% NaCl around the 200 mg/dL mark when stable, and include dextrose in the fluids as glucose approaches 200 mg/dL—best fits the standard approach to fluid management as glucose falls.

Starting with lactated Ringer’s is less typical in DKA management, and starting with half-normal saline too early can compromise intravascular resuscitation. Never adding dextrose risks hypoglycemia and halting ongoing correction of ketosis.