What trials or scores guide the management of euglycemic diabetic ketoacidosis (DKA)?

Management of Euglycemic Diabetic Ketoacidosis (eDKA)

There are no specific trials or scoring systems dedicated to euglycemic DKA; management follows standard DKA protocols with modifications for the unique presentation of normal blood glucose levels.

Definition and Diagnostic Criteria

Euglycemic DKA is characterized by:

• Blood glucose <250 mg/dL (often <200 mg/dL)
• Arterial pH <7.3
• Serum bicarbonate <15-18 mEq/L
• Presence of ketones in blood or urine 1

Risk Factors and Precipitating Conditions

Euglycemic DKA is associated with:

• SGLT2 inhibitor use (most common newer cause) 2, 1
• Pregnancy 2
• Reduced caloric intake or starvation 1
• Alcohol consumption 1
• Chronic liver disease 1
• Recent insulin use 1
• Glycogen storage disorders 1

Assessment Algorithm

1. Laboratory evaluation:

   • Arterial blood gases (pH, bicarbonate)
   • Serum ketones (β-hydroxybutyrate preferred over nitroprusside method)
   • Complete blood count
   • Comprehensive metabolic panel
   • Anion gap calculation
   • Urinalysis with ketones 2

2. Key differential diagnoses:

   • Starvation ketosis (bicarbonate usually not <18 mEq/L)
   • Alcoholic ketoacidosis
   • Other causes of high anion gap metabolic acidosis (lactic acidosis, salicylate, methanol, ethylene glycol ingestion) 2

Management Protocol

Initial Resuscitation

1. Fluid replacement:

   • Isotonic saline (0.9% NaCl) at 15-20 ml/kg/h for the first hour (1-1.5 L in average adult) 2
   • Subsequent fluid choice based on hydration status and electrolytes:
     • 0.45% NaCl at 4-14 ml/kg/h if corrected sodium normal/elevated
     • 0.9% NaCl at similar rate if corrected sodium low 2

2. Insulin therapy:

   • Critical point: Despite euglycemia, insulin is still required to suppress ketogenesis
   • Regular insulin IV infusion at 0.1 units/kg/h after initial bolus
   • Add dextrose when glucose <200 mg/dL while continuing insulin to clear ketosis 2

3. Electrolyte replacement:

   • Potassium: Add 20-30 mEq/L (2/3 KCl and 1/3 KPO4) once renal function is assured 2
   • Monitor electrolytes every 2-4 hours 2

Monitoring

• Blood glucose every 1-2 hours
• Electrolytes, BUN, creatinine every 2-4 hours
• Venous pH and anion gap to follow resolution of acidosis
• Caution: Do not rely on nitroprusside method for ketone monitoring as it measures acetoacetate/acetone but not β-hydroxybutyrate 2

Resolution Criteria

• Glucose <200 mg/dL
• Serum bicarbonate ≥18 mEq/L
• Venous pH ≥7.3 2

Special Considerations

SGLT2 Inhibitor-Associated eDKA

• Discontinue SGLT2 inhibitor
• Higher glucose requirements may be needed during treatment
• Consider holding SGLT2 inhibitors 3-4 days before planned procedures 2

Pregnancy

• Higher risk for euglycemic DKA
• More aggressive monitoring and treatment needed due to feto-maternal risks
• Lower threshold for diagnosis as mixed acid-base disturbances may be present 2

Transition from IV to Subcutaneous Insulin

• Administer basal insulin 2-4 hours before stopping IV insulin to prevent rebound ketosis
• Consider low-dose basal insulin analog in addition to IV insulin to prevent rebound hyperglycemia 2

Prevention Strategies

• Patient education about risk factors
• Blood or urine ketone monitoring during illness, especially with SGLT2 inhibitor use
• Never discontinue basal insulin during illness, even when not eating
• Provide detailed sick-day management instructions 2

Common Pitfalls

1. Delayed diagnosis due to normal glucose levels
2. Premature discontinuation of insulin when glucose normalizes
3. Failure to add dextrose when treating with insulin
4. Relying solely on nitroprusside method for ketone monitoring
5. Overlooking the need for continued insulin despite euglycemia

Despite the euglycemic presentation, ketoacidosis remains a medical emergency requiring prompt and appropriate treatment with the same urgency as traditional DKA 1, 3.