A 24-year-old man with type 1 diabetes presents with a 2-day history of vomiting and abdominal pain. Blood glucose is 480 mg/dL, pH 7.12, bicarbonate 8 mEq/L, serum potassium 4.8 mEq/L, and urine ketones are strongly positive. He is alert with BP 110/70 mmHg. What is the correct initial intravenous fluid prescription?
- A 0.9% sodium chloride at 15 to 20 mL/kg over the first hour ✓
- B 0.45% sodium chloride at 15 to 20 mL/kg over the first hour
- C 5% dextrose in water at 250 mL per hour until glucose falls below 250 mg/dL
- D Isotonic sodium bicarbonate infused over the first hour to correct acidosis
Correct answer: A. 0.9% sodium chloride at 15 to 20 mL/kg over the first hour
Explanation
In diabetic ketoacidosis the first hour requires isotonic (0.9%) saline at 15 to 20 mL/kg to restore circulating volume. Half-normal saline is reserved for later replacement when the corrected serum sodium is high or osmolality is elevated. Dextrose is added only once glucose falls near 250 mg/dL, and bicarbonate is not recommended unless pH is below 6.9.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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