What to do in a patient with Diabetic Ketoacidosis (DKA) who has a blood glucose level of 6 mmol/L, an anion gap of 18, and significant acidosis with high ketone levels?

Management of Euglycemic Diabetic Ketoacidosis (DKA)

In a patient with DKA who has a normal blood glucose level (6 mmol/L), persistent anion gap of 18, and high blood ketones, continue intravenous insulin therapy with concurrent dextrose administration to resolve ketoacidosis while preventing hypoglycemia. 1

Initial Assessment and Management

1. Recognize Euglycemic DKA

   • This is a case of euglycemic DKA, where ketoacidosis persists despite normal blood glucose levels
   • The diagnosis is confirmed by:
     • Anion gap of 18 (elevated)
     • High ketone levels in blood
     • Persistent acidosis
     • Normal blood glucose (6 mmol/L)

2. Immediate Interventions

   • Continue IV insulin therapy at 0.1 U/kg/hour 1
   • Add dextrose-containing fluids when glucose is <200 mg/dL (11.1 mmol/L) 1
     • Use 5% or 10% dextrose solution
     • This allows continued insulin administration to clear ketones without causing hypoglycemia

Fluid and Electrolyte Management

• Continue fluid resuscitation with isotonic saline (0.9% NaCl) at 4-14 ml/kg/h 1
• Monitor electrolytes every 2-4 hours until normalized 1
• Potassium replacement:
  • Ensure potassium levels remain in normal range
  • Add 20-30 mEq/L potassium to IV fluids once renal function is assured
  • Use 2/3 KCl and 1/3 KPO₄ for balanced replacement 1

Monitoring and Adjustments

• Monitor blood glucose hourly to prevent hypoglycemia 1
• Check venous pH, bicarbonate, and anion gap every 2-4 hours until resolution 1
• Adjust insulin infusion rate based on the rate of ketone clearance, not just glucose levels
• Continue insulin infusion until resolution criteria are met:
  • Serum bicarbonate ≥18 mEq/L
  • Venous pH ≥7.3
  • Anion gap normalized 1

Common Pitfalls and Caveats

• Do not stop insulin therapy prematurely when glucose normalizes - ketoacidosis may still be present and requires ongoing insulin to resolve 2

• Avoid bicarbonate therapy unless pH is severely low (<6.9) 1

• Consider underlying causes of euglycemic DKA:

  • SGLT2 inhibitor use 3
  • Starvation or low carbohydrate intake 3
  • Pregnancy
  • Reduced caloric intake with continued insulin use

• Watch for hypoglycemia which can develop rapidly with continued insulin therapy 4

  • Have glucose-containing solutions readily available
  • Consider reducing insulin infusion rate if glucose falls below 100 mg/dL (5.6 mmol/L) while maintaining adequate ketone clearance

Transition to Subcutaneous Insulin

• Only transition to subcutaneous insulin after DKA has resolved (normal anion gap, pH ≥7.3, bicarbonate ≥18 mEq/L) 1
• Continue IV insulin for 1-2 hours after first subcutaneous dose to prevent recurrence 1
• Initial subcutaneous regimen: 0.6-1.0 U/kg/day divided into basal and bolus doses 1

Patient Education Before Discharge

• Educate on recognition of early warning signs of DKA 1
• Provide sick day management protocols 1
• Ensure uninterrupted access to diabetes medications 1, 5
• Regular blood glucose monitoring especially during illness 1

Remember that euglycemic DKA is a dangerous condition that requires the same aggressive management as hyperglycemic DKA, with the additional challenge of preventing hypoglycemia while clearing ketones.