Treatment of Euglycemic Diabetic Ketoacidosis (DKA)
The treatment of euglycemic DKA follows the same principles as traditional DKA, with the critical distinction that dextrose-containing fluids must be administered along with insulin therapy from the beginning of treatment to prevent hypoglycemia while resolving ketoacidosis. 1, 2
Initial Management
Fluid Replacement
- Administer isotonic saline (0.9% NaCl) at 15-20 ml/kg/h during the first hour to treat dehydration 1
- After initial resuscitation, transition to balanced crystalloids (e.g., Lactated Ringer's) at 4-14 ml/kg/h based on hydration status 1
- Unlike traditional DKA, immediately include dextrose in IV fluids (typically 5% dextrose) to maintain blood glucose levels while treating ketoacidosis 2, 3
Insulin Therapy
- Administer regular insulin by continuous intravenous infusion at 0.1 U/kg/hour without an initial bolus 1
- Monitor blood glucose hourly to prevent hypoglycemia 1, 4
- Continue insulin infusion until ketoacidosis resolves (normalized anion gap, bicarbonate ≥18 mEq/L, pH >7.3) regardless of blood glucose levels 1, 5
Electrolyte Management
- Begin potassium replacement when serum levels fall below 5.5 mEq/L, using 20-30 mEq/L of potassium (2/3 KCl and 1/3 KPO₄) once renal function is assured 1
- Monitor electrolytes, BUN, creatinine, and venous pH every 2-4 hours to guide treatment 1
Key Differences in Euglycemic DKA Management
- Modified DKA protocol: Begin dextrose-containing IV fluids immediately rather than waiting for glucose to fall below 250 mg/dL 6, 3
- Focus on resolving ketoacidosis rather than normalizing blood glucose 5, 7
- Continue insulin therapy until ketoacidosis resolves, even if blood glucose levels are normal 3
Monitoring and Resolution Criteria
- Monitor blood glucose hourly during insulin infusion 1, 4
- Check electrolytes, BUN, creatinine, and venous pH every 2-4 hours 1
- DKA is considered resolved when:
Common Pitfalls in Euglycemic DKA Management
- Delayed diagnosis due to normal blood glucose levels masking the underlying ketoacidosis 3, 7
- Inadequate insulin therapy due to concerns about hypoglycemia 5
- Premature discontinuation of insulin before ketoacidosis resolves 5
- Failure to identify and treat precipitating causes (e.g., SGLT-2 inhibitor use, infection, insulin pump failure) 2, 7
Transition to Subcutaneous Insulin
- Administer basal insulin 2-4 hours before discontinuing IV insulin to prevent hyperglycemic rebound 1
- Ensure patient education on diabetes management before discharge 1
- Schedule follow-up appointment for continued diabetes care 1
By following this approach, euglycemic DKA can be effectively managed while avoiding the complications of hypoglycemia and ensuring complete resolution of ketoacidosis.