What is the initial workup and management for a patient presenting with euglycemic diabetic ketoacidosis (DKA)?

Initial Workup and Management of Euglycemic Diabetic Ketoacidosis

The initial workup and management of euglycemic diabetic ketoacidosis (euDKA) should follow the same principles as classic DKA, with immediate arterial blood gas analysis, serum ketone measurement, and prompt initiation of intravenous fluids with concurrent dextrose and insulin therapy. 1, 2

Diagnostic Criteria for Euglycemic DKA

Euglycemic DKA is characterized by:

• Blood glucose <250 mg/dL (or <11 mmol/L) 2
• Arterial pH <7.3
• Serum bicarbonate <15 mEq/L
• Presence of ketonemia/ketonuria
• Anion gap metabolic acidosis 1, 2

Initial Workup

1. Laboratory Assessment:

   • Arterial blood gas (ABG) to confirm metabolic acidosis
   • Comprehensive metabolic panel (including electrolytes, BUN, creatinine)
   • Serum ketones (β-hydroxybutyrate preferred over acetoacetate)
   • Complete blood count
   • Urinalysis for ketones
   • Calculate anion gap 1, 2

2. Additional Investigations:

   • Electrocardiogram (to assess for cardiac abnormalities and effects of electrolyte disturbances)
   • Chest X-ray (if respiratory symptoms present)
   • Blood, urine, and other cultures if infection suspected 1

3. Precipitating Factor Assessment:

   • Medication history (especially SGLT-2 inhibitors, which are common causes of euDKA) 2, 3
   • Recent illness or infection
   • Pregnancy status
   • Recent fasting, surgery (particularly bariatric), or reduced carbohydrate intake
   • Insulin pump failure or insulin omission 2

Management Protocol

1. Fluid Resuscitation

• Begin with isotonic saline at 15-20 mL/kg/hour for the first hour 1
• Critical difference from classic DKA: Early introduction of dextrose-containing fluids (D5W or D10W) even with normal glucose levels to provide substrate for metabolism and prevent hypoglycemia 2, 3
• After initial resuscitation, transition to 0.45% saline at 4-14 mL/kg/hour based on corrected sodium levels 1

2. Insulin Therapy

• Start continuous IV regular insulin infusion at 0.1 units/kg/hour without an initial bolus 1
• If patient has chronic kidney disease or heart failure, consider reduced rate of 0.05 units/kg/hour 1
• Continue insulin infusion until resolution of ketoacidosis (not just normalization of blood glucose) 1, 2
• Target glucose reduction rate: 50-70 mg/dL/hour 1

3. Electrolyte Management

• Monitor potassium closely and begin replacement when serum K+ <5.5 mEq/L
• Add 20-30 mEq/L potassium to IV fluids (2/3 KCl and 1/3 KPO₄) 1
• Monitor and replace phosphate, especially with severe hypophosphatemia 1
• Calculate corrected sodium: Measured sodium + 1.6 × [(glucose mg/dL - 100)/100] 1

4. Monitoring

• Hourly: Vital signs, neurological status, blood glucose, fluid input/output
• Every 2-4 hours: Electrolytes, BUN, creatinine, venous pH
• Continuous cardiac monitoring 1

Special Considerations for Euglycemic DKA

1. SGLT-2 Inhibitor-Associated euDKA:

   • Discontinue SGLT-2 inhibitor immediately
   • Expect potentially prolonged course due to drug half-life 3
   • May require higher dextrose concentrations in IV fluids

2. Pregnancy-Associated euDKA:

   • Lower threshold for diagnosis (pH <7.35)
   • More aggressive monitoring and management
   • Fetal monitoring if applicable 2

3. Resolution Criteria:

   • Serum bicarbonate ≥18 mEq/L
   • Venous pH >7.3
   • Anion gap normalized
   • Resolution of ketonemia 1

Complications to Monitor

• Cerebral edema (rare in adults, more common in children)
• Hypoglycemia (higher risk in euDKA due to lower initial glucose)
• Hypokalemia
• Fluid overload
• Hyperchloremic metabolic acidosis 1

Common Pitfalls in euDKA Management

1. Delayed diagnosis due to absence of significant hyperglycemia - always check ketones and ABG in diabetic patients with acidosis even if glucose is near normal 2

2. Premature discontinuation of insulin once glucose normalizes - continue insulin until ketoacidosis resolves 2, 3

3. Inadequate dextrose administration - euDKA requires concurrent dextrose and insulin to resolve ketosis 3

4. Failure to identify and address the precipitating cause - particularly SGLT-2 inhibitors, which may need to be discontinued permanently 2, 3