What is the treatment for euglycemic acidosis, particularly in the context of diabetic ketoacidosis (DKA)?

Treatment of Euglycemic Diabetic Ketoacidosis

Euglycemic diabetic ketoacidosis (EDKA) should be treated with the same protocol as traditional DKA, with the critical addition of dextrose-containing fluids alongside insulin therapy to prevent hypoglycemia while resolving ketoacidosis. 1

Diagnosis and Recognition

Euglycemic DKA is characterized by:

• Metabolic acidosis (pH <7.3, bicarbonate <15 mEq/L)
• Ketonemia (>3 mmol/L) or ketonuria
• Blood glucose <250 mg/dL (often <200 mg/dL) 1, 2

This condition is often missed due to the absence of significant hyperglycemia, leading to delayed treatment and potentially worse outcomes 1.

Treatment Protocol

1. Fluid Resuscitation

• Begin with isotonic saline (0.9% NaCl) at 15-20 ml/kg/hour initially 3
• Critical difference from standard DKA: Transition early to dextrose-containing fluids (5% glucose in 0.45% saline) to maintain euglycemia while treating ketoacidosis 1, 4
• Continue fluid replacement until dehydration is corrected and oral fluids are tolerated

2. Insulin Therapy

• Start continuous intravenous insulin infusion at 0.1 U/kg/hour 3
• Do not delay insulin therapy despite lower glucose levels
• Continue insulin infusion until metabolic acidosis resolves (pH >7.3, bicarbonate ≥18 mEq/L, normalized anion gap) 3
• Monitor glucose closely to prevent hypoglycemia; adjust dextrose concentration as needed

3. Electrolyte Management

• Replace potassium when levels are <5.5 mEq/L and renal function is adequate
• Add 20-30 mEq/L potassium to IV fluids (2/3 KCl and 1/3 KPO₄) 3
• Monitor electrolytes every 2-4 hours during treatment

4. Monitoring

• Blood glucose: every 1-2 hours
• Electrolytes, BUN, creatinine: every 2-4 hours
• Venous pH and anion gap: every 2-4 hours
• Cardiac monitoring for T-wave changes indicating hypo/hyperkalemia 3

5. Resolution and Transition

• EDKA resolution criteria: venous pH >7.3, serum bicarbonate ≥18 mEq/L, normalized anion gap, and hemodynamic stability 3
• Transition to subcutaneous insulin after resolution of ketoacidosis
• Continue IV insulin for 1-2 hours after first subcutaneous insulin dose 3

Special Considerations for EDKA

Common Causes to Address

• SGLT2 inhibitor use (most common modern cause)
• Pregnancy
• Fasting or starvation
• Low carbohydrate/ketogenic diets
• Insulin pump failure
• Gastroparesis
• Chronic liver disease 1, 4

Pitfalls to Avoid

1. Delayed diagnosis due to normal glucose levels - always check ketones and pH in ill diabetic patients regardless of glucose level 2
2. Insufficient dextrose administration - unlike traditional DKA, patients need glucose supplementation alongside insulin to resolve ketosis 1, 4
3. Premature discontinuation of insulin therapy when glucose normalizes - continue insulin until ketoacidosis resolves 1

Modified Protocol for Resource-Limited Settings

In settings without ICU availability, a modified protocol can be considered:

• Transition to oral fluids when tolerated
• Switch to subcutaneous rapid-acting insulin analog at 0.15 U/kg every 2-3 hours until resolution of metabolic acidosis
• Initiate intermediate-acting insulin approximately 12 hours after treatment initiation 5

However, this approach should only be used when standard IV protocols cannot be implemented due to resource constraints.