What is the protocol for managing euglycemic Diabetic Ketoacidosis (DKA)?

Management Protocol for Euglycemic Diabetic Ketoacidosis (DKA)

The management of euglycemic DKA 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 Diagnosis

Euglycemic DKA is characterized by:

• Metabolic acidosis (pH <7.3, bicarbonate <15 mEq/L)
• Ketonemia or moderate ketonuria
• Relatively normal blood glucose (<250 mg/dL)

Diagnostic Workup

• Arterial blood gases
• Complete blood count with differential
• Blood glucose
• Serum ketones (preferably β-hydroxybutyrate)
• Electrolytes and anion gap calculation
• Blood urea nitrogen/creatinine
• Urinalysis
• ECG

Treatment Protocol

1. Fluid Resuscitation

• Initial fluid therapy: Isotonic saline (0.9% NaCl) at 15-20 mL/kg/hour for the first hour 1
• Subsequent fluid therapy:
  • If corrected serum sodium is normal/elevated: 0.45% NaCl at 4-14 mL/kg/hour
  • If corrected serum sodium is low: Continue 0.9% NaCl at similar rate
• Critical difference for euglycemic DKA: Include dextrose-containing fluids (5-10% dextrose) once insulin therapy begins 2, 3

2. Insulin Therapy

• Begin continuous intravenous regular insulin at 0.1 units/kg/hour 4
• Do not reduce insulin dose even if blood glucose falls, as insulin is needed to suppress ketogenesis
• Continue insulin until ketoacidosis resolves (pH >7.3, bicarbonate ≥18 mEq/L, normal anion gap)

3. Electrolyte Replacement

• Potassium: Add 20-30 mEq/L of potassium (2/3 KCl and 1/3 KPO₄) to IV fluids when:
  • Serum potassium <5.5 mEq/L
  • Adequate urine output is confirmed
• Phosphate: Consider replacement if serum phosphate <1.0 mg/dL or in patients with cardiac dysfunction, anemia, or respiratory depression 4
• 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 until acidosis resolves
• Vital signs and neurological status: Hourly

5. Transition to Subcutaneous Insulin

• Begin subcutaneous insulin when:
  • DKA has resolved (pH >7.3, bicarbonate ≥18 mEq/L, normal anion gap)
  • Patient can tolerate oral intake
• Continue IV insulin for 1-2 hours after first subcutaneous dose 4

Special Considerations for Euglycemic DKA

• Maintain blood glucose between 150-200 mg/dL during treatment 2
• Never withhold insulin due to normal glucose levels, as insulin is required to suppress ketogenesis
• Always administer dextrose-containing fluids alongside insulin to prevent hypoglycemia while treating ketoacidosis
• Identify and address precipitating factors:
  • SGLT2 inhibitor use
  • Pregnancy
  • Reduced carbohydrate intake/ketogenic diet
  • Alcohol consumption
  • Prolonged fasting

Resolution Criteria

DKA is considered resolved when:

• Blood glucose <200 mg/dL
• Serum bicarbonate ≥18 mEq/L
• Venous pH >7.3
• Anion gap normalized
• Patient is hemodynamically stable 4

Common Pitfalls to Avoid

• Delayed diagnosis due to normal glucose levels
• Withholding insulin because of normal glucose levels
• Failing to administer dextrose alongside insulin
• Inadequate monitoring of acid-base status and electrolytes
• Not identifying precipitating factors that need to be addressed

By following this protocol, clinicians can effectively manage euglycemic DKA while minimizing the risk of complications such as hypoglycemia, cerebral edema, and electrolyte disturbances.