What is the management approach for euglycemic DKA?

Management Approach for Euglycemic DKA

The management of euglycemic diabetic ketoacidosis (euDKA) follows the same core principles as traditional DKA, with the critical addition of dextrose-containing fluids alongside insulin therapy to prevent hypoglycemia while resolving ketoacidosis.

Definition and Recognition

Euglycemic DKA is characterized by:

• Metabolic acidosis (pH <7.3, bicarbonate <15 mEq/L)
• Ketonemia/ketonuria
• Blood glucose <250 mg/dL (often much lower)

Initial Assessment and Management

1. Fluid Resuscitation:

   • Begin with isotonic saline (0.9% NaCl) at 15-20 mL/kg/hr during the first hour 1
   • After initial resuscitation, transition to dextrose-containing fluids when glucose is <200-250 mg/dL
   • Continue aggressive fluid replacement to restore circulatory volume and tissue perfusion

2. Insulin Therapy:

   • For moderate to severe cases: Continuous IV insulin infusion (0.1 units/kg/hr) 1
   • Critical difference from traditional DKA: Add dextrose (D5W or D10W) when glucose is <200 mg/dL to prevent hypoglycemia while continuing insulin to clear ketones 2
   • For mild cases: Consider subcutaneous rapid-acting insulin analogs (0.15 units/kg every 2-3 hours) 1, 3

3. Electrolyte Management:

   • Monitor potassium closely and begin replacement when K+ <5.3 mEq/L
   • Add 20-30 mEq/L potassium (2/3 KCl and 1/3 KPO4) to IV fluids once renal function is confirmed 1
   • Monitor phosphate, magnesium, and calcium; replace as needed

4. Acid-Base Management:

   • Bicarbonate therapy is generally not recommended if pH >7.0 1
   • Consider bicarbonate only if pH <6.9 (50 mmol sodium bicarbonate diluted in 200 mL sterile water infused at 200 mL/hr) 1

5. Monitoring:

   • Check blood glucose, electrolytes, venous pH, and anion gap every 2-4 hours 1
   • Direct measurement of β-hydroxybutyrate in blood is preferred over nitroprusside method for monitoring ketosis 1

Special Considerations for Euglycemic DKA

1. Identify and Address Precipitating Factors:

   • SGLT2 inhibitor use (discontinue immediately) 4, 5, 6
   • Reduced carbohydrate intake or ketogenic diet 7
   • Pregnancy
   • Alcohol consumption
   • Reduced insulin doses

2. Caution with SGLT2 Inhibitors:

   • Discontinue SGLT2 inhibitors 3-4 days before surgery 1
   • Consider temporary discontinuation during acute illness, fasting, or reduced oral intake 4
   • Monitor for signs of ketoacidosis regardless of blood glucose levels in patients taking SGLT2 inhibitors 4

Transition to Subcutaneous Insulin

1. Timing:

   • Begin subcutaneous basal insulin 2-4 hours before stopping IV insulin 1
   • Continue IV insulin for 1-2 hours after first subcutaneous dose to prevent rebound ketoacidosis 1

2. Dosing:

   • Initial basal insulin dose: 0.6-1.0 units/kg/day, adjusted based on patient needs 3
   • Add prandial insulin when patient begins eating

3. Resolution Criteria:

   • Glucose <200 mg/dL
   • Serum bicarbonate ≥18 mEq/L
   • Venous pH >7.3
   • Resolution of ketosis 1

Common Pitfalls and Caveats

1. Diagnostic Delays:

   • Normal or near-normal glucose levels may lead to missed or delayed diagnosis 2, 8
   • Always check for ketones and acidosis in symptomatic diabetic patients, even with normal glucose

2. Treatment Errors:

   • Failing to administer dextrose alongside insulin in euglycemic DKA
   • Discontinuing insulin prematurely when glucose normalizes but ketosis persists
   • Inadequate fluid resuscitation

3. Monitoring Challenges:

   • Nitroprusside method only measures acetoacetic acid and acetone, not β-hydroxybutyrate
   • During treatment, β-hydroxybutyrate converts to acetoacetate, which may falsely suggest worsening ketosis 1

By following this structured approach with special attention to dextrose administration alongside insulin therapy, clinicians can effectively manage euglycemic DKA while avoiding hypoglycemia and ensuring complete resolution of ketoacidosis.