What is the immediate management for a patient presenting with Euglycemic Diabetic Ketoacidosis (DKA)?

Immediate Management of Euglycemic Diabetic Ketoacidosis (DKA)

The immediate management of euglycemic DKA requires aggressive fluid resuscitation with isotonic saline (0.9% NaCl) at 1-1.5 L in the first hour, continuous intravenous insulin infusion at 0.1 U/kg/hour without bolus, and early administration of dextrose-containing fluids to facilitate insulin therapy while avoiding hypoglycemia. 1, 2

Initial Assessment and Diagnosis

• Euglycemic DKA is characterized by:

  • Blood glucose <200 mg/dL
  • Arterial pH <7.3 or bicarbonate <15 mEq/L
  • Presence of ketones in blood (>3 mmol/L) or urine 2, 3

• Common causes to identify during assessment:

  • SGLT2 inhibitor use (most common modern cause)
  • Pregnancy
  • Decreased caloric intake/fasting
  • Recent insulin use
  • Alcohol consumption
  • Chronic liver disease
  • Sepsis 2, 3, 4

Treatment Algorithm

1. Fluid Resuscitation

• Begin with isotonic saline (0.9% NaCl) at 1-1.5 L in first hour for adults
• Continue with 0.9% NaCl or switch to 0.45% NaCl based on corrected serum sodium and hemodynamic status 1
• Critical difference from standard DKA: Add 5-10% dextrose earlier in treatment to facilitate continued insulin administration while avoiding hypoglycemia 2, 3

2. Insulin Therapy

• Initiate continuous IV infusion of regular insulin at 0.1 U/kg/hour without bolus
• Continue insulin infusion until metabolic acidosis resolves (even if glucose is normal)
• Higher percentages of dextrose (10% or 20%) may be required to allow continued insulin administration 1, 2

3. Electrolyte Management

• Begin potassium replacement when serum K+ <5.3 mEq/L and adequate urine output is confirmed
• Typical replacement: 20-30 mEq in each liter of IV fluid
• Important safety note: Hold insulin if K+ <3.3 mEq/L until corrected 1

4. Monitoring

• Hourly assessment of:
  • Vital signs
  • Mental status
  • Blood glucose
  • Electrolytes (especially potassium)
  • Arterial blood gases or venous pH
  • Anion gap 1

Resolution Criteria

DKA is considered resolved when all of the following criteria are met:

• Glucose <200 mg/dL (already met in euglycemic DKA)
• Serum bicarbonate ≥18 mEq/L
• Venous pH >7.3 1

Transition to Subcutaneous Insulin

• Administer basal insulin 2-4 hours before stopping IV insulin to prevent rebound hyperglycemia and recurrence of ketoacidosis
• Recent studies suggest that administering a low dose of basal insulin analog in addition to IV insulin infusion may prevent rebound hyperglycemia 5, 1

Special Considerations for Euglycemic DKA

• Higher risk of delayed diagnosis: The absence of significant hyperglycemia can lead to missed or delayed diagnosis 3, 4
• Dextrose administration: Unlike typical DKA, patients with euglycemic DKA require earlier and potentially higher concentrations of dextrose while continuing insulin therapy 2, 3
• Continued monitoring: Even after apparent clinical improvement, continue monitoring for recurrence of acidosis 1

Common Pitfalls to Avoid

1. Delayed diagnosis due to normal or near-normal glucose levels
2. Premature discontinuation of insulin when glucose normalizes but acidosis persists
3. Inadequate fluid resuscitation due to less obvious dehydration signs
4. Failure to identify and address the underlying cause (especially SGLT2 inhibitors, which should be discontinued)
5. Insufficient dextrose administration during insulin therapy 2, 3, 4

The management of euglycemic DKA requires the same level of urgency as traditional DKA despite the absence of significant hyperglycemia. The key difference is the earlier need for dextrose administration while continuing insulin therapy to resolve ketoacidosis 1, 2, 3.