What is the management of Euglycemic Diabetic Ketoacidosis (DKA)?

Management of Euglycemic Diabetic Ketoacidosis

Euglycemic diabetic ketoacidosis (euDKA) should be treated with the same principles as traditional DKA, with the critical addition of dextrose-containing fluids alongside insulin therapy to prevent hypoglycemia while resolving ketoacidosis. 1

Diagnosis and Initial Assessment

• EuDKA is characterized by ketoacidosis with relatively normal blood glucose (<250 mg/dL), making it a potentially missed diagnosis 2
• Diagnostic criteria include: arterial pH <7.3, serum bicarbonate <15 mEq/L, presence of ketonemia/ketonuria, and blood glucose that may be normal or only mildly elevated 3, 2
• Laboratory evaluation should include plasma glucose, blood urea nitrogen/creatinine, serum ketones, electrolytes with calculated anion gap, osmolality, urinalysis, arterial blood gases, complete blood count, and electrocardiogram 3, 4
• Direct measurement of β-hydroxybutyrate in blood is preferred over nitroprusside method, which only measures acetoacetic acid and acetone 3, 4

Treatment Protocol

Fluid Therapy

• Begin with isotonic saline (0.9% NaCl) at 15-20 mL/kg/hour (approximately 1-1.5 L in the average adult) during the first hour 5, 3, 1
• Continue aggressive fluid management to restore circulatory volume and improve tissue perfusion 1
• Unlike traditional DKA, add dextrose-containing fluids (5% dextrose with 0.45-0.75% NaCl) earlier in treatment to maintain adequate glucose levels while continuing insulin therapy to clear ketosis 3, 1, 2

Insulin Therapy

• Start continuous intravenous regular insulin infusion at 0.1 units/kg/hour without an initial bolus 3, 4
• Continue insulin infusion until resolution of ketoacidosis (pH >7.3, serum bicarbonate ≥18 mEq/L, and anion gap ≤12 mEq/L) regardless of glucose levels 3, 1
• Never interrupt insulin infusion when glucose levels fall; instead, add dextrose to prevent hypoglycemia while continuing insulin to clear ketosis 3, 4

Electrolyte Management

• Monitor potassium levels closely, as insulin therapy and correction of acidosis can cause hypokalemia 3, 4
• Include 20-30 mEq/L potassium (2/3 KCl and 1/3 KPO₄) in the infusion once renal function is assured and serum potassium is <5.3 mEq/L 5, 3
• Maintain serum potassium between 4-5 mmol/L throughout treatment 3, 4
• Bicarbonate administration is generally not recommended for patients with pH >6.9 3, 1, 4

Monitoring During Treatment

• Check blood glucose every 1-2 hours 4
• Draw blood every 2-4 hours to determine serum electrolytes, glucose, blood urea nitrogen, creatinine, osmolality, and venous pH 3, 4
• Follow venous pH and anion gap to monitor resolution of acidosis 3, 4
• Monitor for signs of cerebral edema, particularly in pediatric patients 5, 6

Resolution Parameters and Transition to Subcutaneous Insulin

• DKA resolution requires: glucose stabilization, serum bicarbonate ≥18 mEq/L, venous pH >7.3, and anion gap ≤12 mEq/L 3, 4
• When transitioning to subcutaneous insulin, administer basal insulin 2-4 hours before stopping the intravenous insulin to prevent recurrence of ketoacidosis 5, 1, 4
• Administration of a low dose of basal insulin analog in addition to intravenous insulin infusion may prevent rebound hyperglycemia 5, 1

Common Pitfalls to Avoid

• Failure to recognize euDKA due to absence of significant hyperglycemia 2, 7
• Premature termination of insulin therapy before complete resolution of ketosis 3, 4
• Inadequate carbohydrate administration alongside insulin in euDKA, which can perpetuate ketosis 1, 2
• Interruption of insulin infusion when glucose levels fall without adding dextrose 3, 4
• Inadequate monitoring and replacement of electrolytes, particularly potassium 3, 7
• Relying solely on nitroprusside method to measure ketones, which doesn't detect β-hydroxybutyrate, the predominant ketone body in DKA 3, 4