In diabetic ketoacidosis (DKA) management, which is an appropriate initial fluid therapy?

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In DKA, the first priority is to restore intravascular volume and improve tissue perfusion because osmotic diuresis has caused significant dehydration and reduced effective circulating volume. Isotonic saline (0.9% NaCl) does this best because it expands the extracellular fluid without rapidly changing serum osmolality, helping to improve kidney perfusion and accelerate clearance of ketones once insulin is started. Starting with hypotonic fluids would not adequately restore circulating volume and can disrupt osmolar balance, while giving dextrose-containing fluids right away would delay ketosis resolution and insulin therapy. Fluids are then adjusted based on the patient’s corrected sodium and ongoing needs, with dextrose-containing fluids used later when glucose falls to about 200 mg/dL to prevent hypoglycemia while continuing insulin to resolve ketoacidosis.