In the management of diabetic ketoacidosis, what is considered the most important initial step?

• A. Immediate insulin infusion
• B. Bolus fluids until the patient stabilizes
• C. Potassium replacement
• D. Phosphorus supplementation

Answer: (B)

Restoring circulating volume with intravenous fluids is the first priority in DKA management. Patients are severely dehydrated from osmotic diuresis and vomiting, so giving an isotonic fluid bolus improves blood pressure and organ perfusion, supports kidney function, and begins reversing the metabolic derangements. Until the patient is adequately resuscitated and perfusion stabilized, starting insulin or aggressively correcting electrolytes can be dangerous because insulin drives potassium into cells and can worsen hypoperfusion if fluids aren’t yet adequate. After fluids are begun, potassium status guides the next steps: if potassium is low, you correct it (potassium replacement) and may delay insulin until K+ is safe; if potassium is normal or high, you proceed with insulin while continuing electrolyte management. Phosphorus supplementation is not routinely required in the initial management.