What is the management of euglycemic Diabetic Ketoacidosis (DKA)?

Management of Euglycemic Diabetic Ketoacidosis

Euglycemic DKA should be treated with the same aggressive approach as traditional DKA, including IV fluids, insulin therapy, and electrolyte replacement, with the critical addition of dextrose-containing fluids to accompany insulin therapy to prevent hypoglycemia. 1

Diagnosis

Euglycemic DKA is characterized by:

• Ketoacidosis with relatively normal blood glucose (<250 mg/dL)
• Arterial pH <7.3
• Serum bicarbonate <15-18 mEq/L
• Positive serum ketones
• Anion gap >10-12

Common causes include:

• SGLT2 inhibitor use
• Pregnancy
• Reduced carbohydrate intake or fasting
• Recent insulin use
• Alcohol consumption
• Chronic liver disease
• Glycogen storage disorders 1, 2

Treatment Algorithm

1. Fluid Resuscitation

• Initial fluid therapy: isotonic saline (0.9% NaCl) at 15-20 ml/kg/hr during first hour (typically 1-1.5 L in adults) 3
• Subsequent fluid choice:
  • If corrected serum sodium is normal or elevated: 0.45% NaCl at 4-14 ml/kg/hr
  • If corrected serum sodium is low: 0.9% NaCl at similar rate
• Critical difference from standard DKA: Switch to dextrose-containing fluids (5% dextrose in 0.45% saline) once initial volume resuscitation is complete, even if blood glucose remains normal 1

2. Insulin Therapy

• Regular insulin by continuous IV infusion at 0.1 units/kg/hr 3
• If glucose falls below 200 mg/dL (which may occur quickly in euglycemic DKA):
  • Do NOT reduce insulin rate until acidosis resolves
  • Instead, increase dextrose concentration in IV fluids to maintain glucose 150-200 mg/dL while continuing insulin infusion 3
• For mild cases only: Consider subcutaneous insulin regimen (0.4-0.6 units/kg priming dose, followed by 0.1 unit/kg hourly) 3

3. Electrolyte Replacement

• Potassium:
  • Add 20-30 mEq/L potassium (2/3 KCl and 1/3 KPO4) to IV fluids once renal function is confirmed
  • Adjust based on serum potassium levels measured every 2-4 hours 3
• Phosphate: Consider replacement in patients with cardiac dysfunction, anemia, respiratory depression, or serum phosphate <1.0 mg/dL 3
• Bicarbonate: Generally not recommended unless pH <6.9 3

4. Monitoring

• Check serum electrolytes, glucose, BUN, creatinine, and venous pH every 2-4 hours 3
• Important: Monitor beta-hydroxybutyrate (β-OHB) in blood if available, as it's more accurate than nitroprusside method (which only measures acetoacetic acid and acetone) 3
• Continue treatment until:
  • Glucose <200 mg/dL
  • Serum bicarbonate ≥18 mEq/L
  • Venous pH >7.3 3

5. Transition to Subcutaneous Insulin

• Once DKA resolves, if patient can eat:
  • Start multiple-dose insulin schedule with combination of short/rapid-acting and intermediate/long-acting insulin
  • Continue IV insulin infusion for 1-2 hours after subcutaneous insulin is initiated to prevent rebound ketoacidosis 3
• If patient remains NPO:
  • Continue IV insulin and fluid replacement
  • Supplement with subcutaneous regular insulin as needed (5-unit increments for every 50 mg/dL increase in blood glucose above 150 mg/dL) 3

Special Considerations

• Identify and treat precipitating factors (infection, myocardial infarction, stroke, etc.) 3
• Euglycemic DKA can be easily missed due to normal glucose levels - maintain high clinical suspicion in at-risk patients 1, 2
• Pregnant patients, those on SGLT2 inhibitors, and patients with reduced carbohydrate intake require particular vigilance 1, 2
• Despite euglycemia, ketoacidosis remains a medical emergency requiring prompt treatment 2

Common Pitfalls

• Delaying treatment due to normal glucose levels
• Reducing insulin infusion rate when glucose is normal or low
• Failing to administer dextrose-containing fluids with insulin
• Using nitroprusside method to monitor ketone clearance (use direct β-OHB measurement if available)
• Abruptly discontinuing IV insulin without proper transition to subcutaneous regimen