Diabetic Ketoacidosis: The Daily PANCE Blueprint

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Diabetic Ketoacidosis: The Daily PANCE Blueprint

A 19-year-old woman with type 1 diabetes presents with one day of nausea, vomiting, and diffuse abdominal pain after a viral illness during which she skipped several insulin doses. She has deep, rapid (Kussmaul) breathing and a fruity breath odor. T 37.2°C, HR 118, BP 104/68, RR 26. Labs: glucose 486 mg/dL, pH 7.18, HCO3 11 mEq/L, anion gap 25, ketones positive, K⁺ 5.1 mEq/L, creatinine 1.3 mg/dL. Which of the following is the most appropriate initial step in management?

A. Rapid IV infusion of 0.9% sodium chloride
B. IV regular insulin bolus followed by infusion
C. IV sodium bicarbonate
D. IV potassium chloride
E. Subcutaneous rapid-acting insulin

Answer and topic summary

The answer is A. Rapid IV infusion of 0.9% sodium chloride

DKA management begins with aggressive isotonic IV fluids (0.9% NaCl) to restore intravascular volume — before insulin. Per the ADA Standards of Care in Diabetes (2025), the insulin infusion starts after initial fluids and only once K⁺ is ≥3.3 mEq/L. Bicarbonate is reserved for pH <6.9; potassium is added once K⁺ <5.2–5.3 mEq/L with adequate urine output. Subcutaneous insulin is too slow for moderate–severe DKA.

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Covered under ⇒ PANCE Blueprint Endocrinology ⇒ Diabetes Mellitus ⇒ Diabetic ketoacidosis

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