How is euglycemic diabetic ketoacidosis (DKA) diagnosed and treated?

Diagnosis and Management of Euglycemic Diabetic Ketoacidosis (EDKA)

Euglycemic diabetic ketoacidosis is diagnosed when a patient presents with metabolic acidosis, ketosis, and blood glucose levels <250 mg/dL, and requires immediate treatment with IV fluids and insulin despite the absence of significant hyperglycemia. 1

Diagnostic Criteria for EDKA

EDKA is characterized by the following triad:

• Blood glucose <250 mg/dL (often <200 mg/dL)
• Venous pH <7.3 or serum bicarbonate <15 mEq/L
• Presence of moderate to high ketones in blood or urine 1, 2

Initial Laboratory Evaluation

• Arterial or venous blood gases (pH, bicarbonate)
• Serum electrolytes with calculated anion gap
• Blood glucose
• Blood urea nitrogen/creatinine
• Blood β-hydroxybutyrate (βOHB) measurement (preferred method for diagnosis)
• Complete blood count with differential
• Electrocardiogram 1

Important Diagnostic Considerations

1. Blood ketone measurement: Direct measurement of β-hydroxybutyrate in blood is the preferred method for diagnosing EDKA 1
2. Avoid relying on nitroprusside method: This method only measures acetoacetic acid and acetone, not βOHB (the predominant ketone in DKA) 1
3. Calculate anion gap: High anion gap metabolic acidosis is characteristic of EDKA 1

Common Causes of EDKA

EDKA should be suspected in patients with:

• SGLT2 inhibitor use (most common modern cause) 3, 4
• Reduced carbohydrate intake or starvation 5, 3
• Pregnancy 2
• Alcohol consumption 2
• Recent insulin use 2
• Chronic liver disease 2
• Ketogenic diet 5

Treatment Algorithm for EDKA

Initial Management

1. Intravenous fluid resuscitation:

   • Begin with isotonic saline (0.9% NaCl) at 15-20 mL/kg/hour during first hour
   • Subsequent fluid choice depends on hydration status and electrolytes 1

2. Dextrose administration:

   • Unlike traditional DKA, add dextrose (5-10%) early in treatment when blood glucose is <250 mg/dL
   • This allows for continued insulin administration without causing hypoglycemia 1, 5

3. Insulin therapy:

   • Initial IV bolus of regular insulin at 0.15 units/kg body weight
   • Follow with continuous IV insulin infusion at 0.1 unit/kg/hour
   • If glucose doesn't fall by 50 mg/dL in first hour, double insulin rate hourly until steady decline 1
   • Continue insulin infusion until acidosis resolves, even if glucose levels are normal 6

4. Electrolyte replacement:

   • Monitor potassium closely and add to IV fluids once renal function is assured
   • Use 1/3 KPO₄ and 2/3 KCl or K-acetate in solution 1

Monitoring During Treatment

• Check blood glucose, electrolytes, BUN, creatinine every 2-4 hours
• Monitor venous pH and anion gap to track resolution of acidosis
• Use direct βOHB measurement to monitor ketosis resolution rather than nitroprusside method 1

Criteria for Resolution of EDKA

• Serum bicarbonate ≥18 mEq/L
• Venous pH >7.3
• Anion gap normalized 1

Transition to Subcutaneous Insulin

• When EDKA resolves and patient can eat, transition to subcutaneous insulin regimen
• Continue IV insulin for 1-2 hours after starting subcutaneous insulin to ensure adequate plasma insulin levels
• Abrupt discontinuation of IV insulin can lead to recurrence of ketoacidosis 1, 4

Common Pitfalls in EDKA Management

1. Delayed diagnosis due to normal or near-normal glucose levels 6
2. Premature discontinuation of insulin therapy when glucose normalizes but acidosis persists 1
3. Reliance on nitroprusside method for monitoring ketone clearance 1
4. Inadequate fluid resuscitation due to less severe hyperglycemia 1
5. Failure to identify precipitating factors such as SGLT2 inhibitors or starvation 3
6. Abrupt transition from IV to subcutaneous insulin without adequate overlap 1

EDKA is a medical emergency requiring prompt recognition and treatment despite the absence of significant hyperglycemia. The cornerstone of management remains IV fluids, insulin therapy, and electrolyte replacement, with special attention to early dextrose administration to prevent hypoglycemia while continuing insulin infusion to clear ketones 1, 4.