From the Guidelines
Managing diabetic ketoacidosis (DKA) with normal blood glucose levels requires the same core treatment approach as traditional DKA, focusing on aggressive fluid resuscitation, insulin therapy, and electrolyte replacement, as emphasized in the most recent guidelines 1. The treatment should begin with aggressive intravenous fluid resuscitation using 0.9% normal saline at 15-20 mL/kg/hr for the first hour, then adjusted based on hemodynamic status.
- Regular insulin therapy remains essential, starting with an IV bolus of 0.1 units/kg followed by a continuous infusion at 0.1 units/kg/hr, even though blood glucose levels appear normal.
- Electrolyte replacement, particularly potassium, should be initiated when levels fall below 5.3 mEq/L, aiming to maintain levels between 4-5 mEq/L. Unlike typical DKA, dextrose-containing fluids should be started immediately rather than waiting for glucose levels to fall, using D5W or D10W to prevent hypoglycemia while continuing insulin therapy to clear ketones.
- Frequent monitoring of electrolytes, anion gap, pH, and bicarbonate every 2-4 hours is crucial to track resolution, as highlighted in recent studies 1. The underlying cause, often SGLT2 inhibitor use, pregnancy, starvation, or alcohol consumption, must be identified and addressed. Insulin therapy should continue until the anion gap normalizes and ketoacidosis resolves, even if glucose levels remain normal throughout treatment, as recommended by the latest guidelines 1.
From the Research
Management of Diabetic Ketoacidosis (DKA) with Normal Blood Sugar Levels
- DKA can occur with normal blood sugar levels, and the diagnosis may be missed in these cases 2
- Treatment of DKA with normal blood sugar levels includes replacement of fluid and electrolytes lost through osmotic diuresis, and insulin therapy to reverse ketoacid production by the liver 2, 3
- Low-dose insulin therapy is recommended, as it is effective and safe, and can help avoid hypokalemia, hypoglycemia, and osmotic disequilibria 3, 4
- Serum glucose and potassium levels should be monitored closely, and dextrose should be added to the infusion once the serum glucose falls to 250 mg per dl 2
- The treatment protocol should also include the replacement of intracellular fluids with potassium chloride and/or potassium phosphate, and the monitoring of arterial blood gas and serum ketone levels 4, 5
Key Considerations
- Failure to recognize the magnitude of total-body potassium depletion and to begin replacement despite an initially normal serum potassium level may lead to fatal cardiac arrhythmia 2
- The physician must search for the factors precipitating DKA and frequently evaluate the patient's overall condition 5
- A physiologic approach to treatment, incorporating the principles of rehydration of hypertonic states, can help minimize the risk of brain herniation during treatment 6