What are the diagnosis and management of Euglycemic Diabetic Ketoacidosis (DKA)?

Diagnosis and Management of Euglycemic Diabetic Ketoacidosis (DKA)

Euglycemic DKA should be diagnosed and treated as aggressively as traditional DKA despite normal or near-normal blood glucose levels, with immediate insulin therapy and fluid resuscitation being essential for reducing mortality and morbidity. 1, 2

Diagnosis

Definition and Diagnostic Criteria

• Euglycemic DKA is defined as DKA with blood glucose <200 mg/dL (11.1 mmol/L) 1
• Diagnostic criteria include:
  • Blood glucose <200 mg/dL
  • Arterial pH <7.3
  • Serum bicarbonate <18 mEq/L
  • Presence of ketones in blood or urine 2, 3

Laboratory Evaluation

• Essential tests:
  • Arterial blood gases (or venous pH)
  • Complete blood count with differential
  • Plasma glucose
  • Blood urea nitrogen and creatinine
  • Electrolytes and anion gap
  • Direct measurement of β-hydroxybutyrate in blood (preferred over urine ketones) 1, 2
  • Urinalysis
  • Electrocardiogram

Risk Factors and Precipitating Causes

• SGLT2 inhibitor therapy (most common modern cause) 1, 4
• Pregnancy 1
• Reduced food intake/starvation 1, 4
• Very low-carbohydrate or ketogenic diets 5
• Alcohol consumption 3
• Liver disease 3
• Insulin reduction or omission 1
• Acute illness or infection 2
• Gastroparesis 6
• Bariatric surgery 6

Management

Initial Approach

1. Fluid Resuscitation

   • Begin with 0.9% NaCl at 15-20 mL/kg/hr for the first hour 2
   • Adjust subsequent fluid based on hemodynamic status and corrected serum sodium

2. Insulin Therapy

   • Critical difference from standard DKA: Add dextrose-containing fluids when starting insulin therapy or when glucose falls below 200 mg/dL 6
   • For moderate to severe cases: IV regular insulin at 0.1 units/kg/hr after initial bolus of 0.15 units/kg 1, 2
   • For mild cases: Subcutaneous rapid-acting insulin may be used (0.4-0.6 units/kg priming dose, followed by 0.1 unit/hr) 1

3. Electrolyte Replacement

   • Potassium: Add to IV fluids once renal function is assured and serum K+ <5.3 mEq/L
   • Use 1/3 KPO₄ and 2/3 KCl or K-acetate in replacement fluids 1
   • Monitor potassium levels every 2-4 hours

4. Bicarbonate Therapy

   • Generally not recommended unless pH <6.9 1
   • If used, administer 100 mmol in 400 mL water with 20 mEq KCl over 2 hours 1

Monitoring

• Blood glucose every 1-2 hours until stable
• Electrolytes, BUN, creatinine every 2-4 hours
• Venous pH and anion gap to monitor resolution of acidosis
• Monitor β-hydroxybutyrate levels directly rather than using nitroprusside method 1

Transition to Subcutaneous Insulin

• Administer basal insulin 2-4 hours before stopping IV insulin to prevent rebound hyperglycemia 1, 2
• Continue IV insulin infusion for 1-2 hours after starting subcutaneous insulin 1

Resolution Criteria

• Blood glucose <200 mg/dL
• Serum bicarbonate ≥18 mEq/L
• Venous pH ≥7.3 1

Special Considerations

SGLT2 Inhibitor-Associated Euglycemic DKA

• Discontinue SGLT2 inhibitors 3-4 days before planned surgeries 1
• Higher risk with low-carbohydrate diets, prolonged fasting, dehydration, or alcohol intake 1
• May require more aggressive dextrose administration during treatment 4

Pregnancy-Associated Euglycemic DKA

• Lower threshold for diagnosis (can occur at even lower glucose levels)
• Pregnant individuals at risk should be counseled on signs and symptoms
• Requires immediate medical attention due to significant feto-maternal harm 1

Common Pitfalls

1. Delayed diagnosis due to normal glucose levels misleading clinicians 3, 6
2. Inadequate monitoring of ketone resolution (β-hydroxybutyrate conversion to acetoacetate may falsely suggest worsening ketosis with nitroprusside method) 1
3. Premature discontinuation of insulin therapy before ketoacidosis resolves 1
4. Failure to add dextrose when treating euglycemic DKA, leading to hypoglycemia 6
5. Overlooking the underlying precipitating factor that triggered the euglycemic DKA 2, 4

By maintaining a high index of suspicion for euglycemic DKA in at-risk patients with acidosis despite normal glucose levels, clinicians can ensure timely diagnosis and appropriate management of this potentially life-threatening condition.