From the Guidelines

In DKA, intravenous fluids should be administered first to restore circulatory volume and tissue perfusion.

The primary goal in managing DKA is to correct dehydration, electrolyte imbalance, and hyperglycemia, with aggressive fluid replacement being crucial in the initial stages of treatment 1.
Intravenous fluids help to restore blood volume, reduce glucose levels, and improve insulin sensitivity, thereby facilitating the body's response to insulin therapy.
While insulin administration is essential for resolving ketoacidosis, it should be initiated after fluid replacement has been started, as insulin can worsen dehydration if not adequately addressed.
The use of low-dose insulin regimens, such as 0.1 unit/kg/h, is recommended, as they can effectively decrease plasma glucose concentrations without increasing the risk of hypoglycemia 1.
It is also important to monitor electrolyte levels, particularly potassium, and adjust the insulin dose accordingly to prevent hypokalemia.
Blood glucose and ketone levels should be closely monitored to assess the effectiveness of treatment and adjust the insulin dose as needed.
The administration of bicarbonate is generally not recommended, as it has not been shown to improve outcomes in DKA patients 1.

From the Research

The management of DKA involves several key components, including intravenous fluid therapy, insulin administration, and potassium replacement 2, 3, 4.
The order of administration of intravenous fluids and insulin in DKA management is crucial, with current guidelines recommending the use of intravenous fluids to restore fluid status before initiating insulin therapy 3.
The use of intravenous fluids, such as isotonic normal saline, is recommended for initial fluid resuscitation, with the goal of restoring fluid status and improving blood pressure and organ perfusion 3, 4.

Insulin administration is a critical component of DKA management, with the goal of suppressing ketone production and improving glucose uptake 2, 5.
The use of continuous intravenous insulin infusion is recommended, with a dose of 0.1-0.14 units/kg/hour, and may be initiated after fluid status has been restored and potassium levels have been achieved 3, 5.
The use of an initial insulin bolus is controversial, with some studies suggesting that it may not be necessary 5, while others recommend its use to rapidly suppress ketone production 2.

The timing of insulin administration in relation to intravenous fluid administration is important, with current guidelines recommending that insulin be initiated after fluid status has been restored and potassium levels have been achieved 3.
However, the exact timing of insulin administration may vary depending on the individual patient's needs and the severity of their DKA 2, 4.
In general, insulin administration should be initiated as soon as possible after fluid resuscitation has begun, with the goal of rapidly suppressing ketone production and improving glucose uptake 3, 5.