How do you manage euglycemic DKA (diabetic ketoacidosis)?

Management of Euglycemic Diabetic Ketoacidosis

Euglycemic diabetic ketoacidosis (DKA) should be managed with the same aggressive approach as traditional DKA, including intravenous fluids, insulin therapy, and electrolyte replacement, with the critical addition of dextrose-containing fluids alongside insulin to prevent hypoglycemia. 1

Diagnostic Criteria for Euglycemic DKA

Euglycemic DKA is characterized by:

• Blood glucose <250 mg/dL (often <200 mg/dL)
• Metabolic acidosis (venous pH <7.3 or bicarbonate <15 mEq/L)
• Ketonemia/ketonuria
• Anion gap >12 mEq/L

Initial Management

Fluid Resuscitation

• Begin with isotonic saline (0.9% NaCl) at 15-20 mL/kg/hr for the first hour
• Continue with 0.45-0.9% NaCl at 4-14 mL/kg/hr based on hemodynamic status
• Critical difference from standard DKA: Add dextrose-containing fluids (D5W or D10W) when starting insulin therapy, even though blood glucose is not elevated 2, 1

Insulin Therapy

• Start continuous intravenous regular insulin at 0.1 units/kg/hr
• Do not reduce insulin infusion rate when glucose normalizes - continue until ketoacidosis resolves
• Monitor for hypoglycemia and adjust dextrose concentration as needed
• For mild cases only: Consider subcutaneous rapid-acting insulin every 1-2 hours (0.1-0.15 units/kg) 2

Electrolyte Replacement

• Potassium: Add 20-40 mEq/L to IV fluids when serum potassium <5.2 mEq/L and adequate urine output is established
• Monitor potassium, phosphate, and magnesium closely
• Replace as needed to maintain normal levels

Monitoring

• Check blood glucose, electrolytes, venous pH, and anion gap every 2-4 hours
• Use β-hydroxybutyrate levels to monitor ketosis resolution rather than urine ketones 2
• Monitor vital signs and mental status hourly
• Track fluid input/output

Transition to Subcutaneous Insulin

• Begin subcutaneous basal insulin 2-4 hours before stopping IV insulin
• Continue IV insulin until:
  • Blood glucose <200 mg/dL
  • Bicarbonate ≥18 mEq/L
  • Venous pH >7.3
  • Anion gap normalized

Special Considerations for Euglycemic DKA

SGLT2 Inhibitor-Associated Euglycemic DKA

• Discontinue SGLT2 inhibitor immediately
• SGLT2 inhibitors should be discontinued 3-4 days before any planned surgery 2
• Higher dextrose concentrations may be required during treatment

Pregnancy-Related Euglycemic DKA

• Lower threshold for diagnosis (blood glucose may be even lower)
• More aggressive treatment approach with close fetal monitoring
• Consider obstetric consultation

Starvation-Induced Euglycemic DKA

• Address nutritional status
• Provide appropriate caloric intake during recovery

Common Pitfalls to Avoid

1. Delayed diagnosis due to absence of significant hyperglycemia
2. Premature discontinuation of insulin when blood glucose normalizes
3. Inadequate dextrose administration leading to hypoglycemia
4. Failure to identify and treat the underlying precipitating cause
5. Overlooking euglycemic DKA in patients on SGLT2 inhibitors

Discharge Planning

• Identify and address precipitating factors
• Provide education on sick-day management
• Ensure appropriate insulin regimen
• Schedule follow-up within 1-2 weeks
• Consider temporary discontinuation of SGLT2 inhibitors if they were the precipitating cause 2, 3

Remember that despite the absence of significant hyperglycemia, euglycemic DKA represents the same underlying pathophysiology as traditional DKA and carries similar risks for morbidity and mortality if not promptly recognized and appropriately treated.