What is the treatment for euglycemic diabetic ketoacidosis (DKA)?

Treatment of Euglycemic Diabetic Ketoacidosis (DKA)

Euglycemic DKA requires the same urgent treatment protocol as traditional DKA, with the critical addition of dextrose-containing fluids alongside insulin therapy to prevent hypoglycemia while resolving ketoacidosis. 1

Definition and Diagnosis

• Euglycemic DKA is characterized by metabolic acidosis and ketosis with normal or near-normal blood glucose levels (<200 mg/dL) 1
• Diagnosis requires:
  • Arterial pH <7.3
  • Serum bicarbonate <15 mEq/L
  • Moderate ketonemia or ketonuria
  • Blood glucose <200 mg/dL (distinguishing feature from traditional DKA)

Treatment Algorithm

1. Fluid Resuscitation

• Initial phase: Replace 50% of estimated fluid deficit in first 8-12 hours 1
  • Begin with isotonic saline (0.9% NaCl) at 500 mL/hr for first 2-3 liters 2
  • Use caution in patients with cardiac compromise 1
• Second phase: Switch to 5% dextrose in 0.45% saline at 250 mL/hr 2, 3
  • Critical difference from traditional DKA: Dextrose must be added earlier to maintain euglycemia while treating ketoacidosis 4

2. Insulin Therapy

• Administer low-dose intravenous insulin 2
  • Initial bolus: 0.1 units/kg
  • Continuous infusion: 0.1 units/kg/hour
• Do not reduce insulin dose despite normal glucose levels until ketoacidosis resolves 5
• Continue insulin until anion gap normalizes and ketoacidosis resolves 5

3. Electrolyte Replacement

• Potassium: Add to IV fluids when serum potassium <5.3 mEq/L 1
  • 20-30 mEq potassium per liter of IV fluid
  • Critical to replace even if initial levels are normal, as total body potassium is depleted 5
• Monitor electrolytes every 2-4 hours 1

4. Bicarbonate Therapy

• Only indicated when arterial pH <6.9 1
  • For pH <6.9: 100 mmol sodium bicarbonate in 400 mL sterile water at 200 mL/hr
  • For pH 6.9-7.0: 50 mmol sodium bicarbonate in 200 mL sterile water at 200 mL/hr
• Not recommended when pH ≥7.0 1

Monitoring Protocol

• Hourly monitoring:
  • Vital signs
  • Neurological status
  • Blood glucose
  • Fluid input/output 1
• Every 2-4 hours:
  • Electrolytes
  • BUN and creatinine
  • Venous pH 1

Resolution Criteria

DKA is considered resolved when:

• Serum bicarbonate ≥18 mEq/L
• Venous pH >7.3
• Anion gap has normalized 1, 5

Special Considerations

SGLT2 Inhibitor-Associated Euglycemic DKA

• Most common cause of euglycemic DKA in current practice 3, 4
• Discontinue SGLT2 inhibitor immediately
• May require more aggressive dextrose administration 3

Pregnancy

• Pregnant women are at higher risk for euglycemic DKA 1
• Requires immediate attention due to risk of feto-maternal harm
• Lower threshold for ICU admission

Common Pitfalls to Avoid

1. Delayed diagnosis due to normal glucose levels misleading clinicians 4
2. Premature discontinuation of insulin before ketoacidosis resolves 5
3. Inadequate dextrose administration leading to hypoglycemia during treatment 4
4. Failure to identify and treat precipitating factors such as infection, reduced food intake, or medication effects 3, 6
5. Inadequate potassium replacement despite normal initial levels 5

Discharge Planning

• Provide education on:
  • DKA prevention
  • Sick-day management
  • Proper medication administration
  • When to seek medical attention 1
• Schedule follow-up within 1-2 weeks if glycemic management medications were changed 1