From the Guidelines
Management of euglycemic diabetic ketoacidosis (DKA) requires careful attention to glucose levels and involves intravenous fluid resuscitation, insulin administration, and electrolyte replacement, with the goal of restoring circulatory volume, resolving hyperglycemia, and correcting electrolyte imbalance and acidosis, as outlined in the most recent guidelines 1. The management approach should be individualized based on a careful clinical and laboratory assessment, considering the variability in presentation of DKA and hyperosmolar hyperglycemic states. Key aspects of management include:
- Intravenous fluid resuscitation using 0.9% normal saline at 15-20 mL/kg in the first hour, then continuing at 250-500 mL/hr based on hydration status.
- Administering regular insulin as an IV bolus of 0.1 units/kg followed by a continuous infusion at 0.1 units/kg/hr, with the option to use subcutaneous rapid-acting analogs in mild or moderate cases.
- Starting dextrose-containing fluids (D5W or D10W) earlier, often simultaneously with insulin, to prevent hypoglycemia while continuing insulin therapy to clear ketones.
- Electrolyte replacement, particularly potassium, with a goal to maintain levels between 4-5 mEq/L.
- Monitoring blood glucose, electrolytes, pH, and anion gap every 1-2 hours initially.
- Identifying and temporarily discontinuing the underlying cause, such as SGLT2 inhibitors.
- Continuing insulin infusion until the anion gap normalizes and ketosis resolves, even if glucose levels are normal or low, and transitioning to subcutaneous insulin before discontinuing the IV infusion, as recommended in recent guidelines 1. It is essential to note that euglycemic DKA is dangerous because normal glucose levels may delay diagnosis, but the pathophysiology involves insulin deficiency with continued ketogenesis despite normal glycemia, highlighting the importance of prompt and appropriate management based on the latest evidence 1.
From the Research
Management of Euglycemic Diabetic Ketoacidosis (DKA)
The management of euglycemic DKA involves:
- Careful clinical evaluation
- Correction of metabolic abnormalities with intravenous fluids
- Insulin and electrolyte replacement
- Frequent monitoring of the patients' clinical and laboratory findings
- Identification and treatment of the precipitating condition 2
- Restoration of circulating volume, insulin therapy, electrolyte replacement and treatment of any underlying precipitating event 3
- Aggressive treatment with intravenous fluids and insulin drip as per the protocol for the blood glucose levels till the anion gap normalized, and the metabolic acidosis reversed 4
- Correction of fluid and electrolyte abnormalities and the administration of insulin 5
Key Considerations
- Euglycemic DKA poses a challenge to physicians, as patients presenting with normal blood glucose levels in ketoacidosis may be overlooked, leading to a delay in appropriate management strategies 6
- High clinical suspicion is required to diagnose euglycemic DKA as normal blood sugar levels masquerade the underlying DKA and cause a diagnostic and therapeutic dilemma 4
- Blood pH and blood or urine ketones should be checked in ill patients with diabetes regardless of blood glucose levels 4