Primary Differences in Management Between Euglycemic Ketoacidosis and Alcoholic Ketoacidosis
The critical management difference is that euglycemic DKA requires continuous insulin infusion regardless of glucose levels with early dextrose supplementation, while alcoholic ketoacidosis is treated primarily with dextrose-containing fluids and electrolyte replacement WITHOUT insulin. 1, 2
Key Diagnostic Distinctions
Euglycemic Diabetic Ketoacidosis (EuDKA)
- Blood glucose typically <250 mg/dL but with pH <7.3, bicarbonate <15 mEq/L, and positive ketones 2, 3
- Occurs in diabetic patients, often precipitated by SGLT2 inhibitors, ketogenic diets, pregnancy, or reduced carbohydrate intake 4, 3, 5
- β-hydroxybutyrate measurement is preferred over nitroprusside method 2
Alcoholic Ketoacidosis (AKA)
- Glucose ranges from mildly elevated (rarely >250 mg/dL) to hypoglycemia 4
- Distinguished by clinical history of alcohol abuse with preserved mental function despite acidosis 6
- Serum bicarbonate in starvation ketosis usually not lower than 18 mEq/L, but AKA can cause profound acidosis 4
Critical Management Differences
Fluid Therapy
Both conditions: Begin with isotonic saline 15-20 mL/kg/hour during the first hour 1, 2
EuDKA-specific: Add dextrose-containing fluids (5% dextrose with 0.45-0.75% NaCl) EARLY in treatment to maintain glucose levels while continuing insulin therapy 2
AKA-specific: Target blood glucose 100-180 mg/dL with dextrose administration as primary therapy 1
Insulin Management: The Defining Difference
EuDKA:
- Start continuous IV regular insulin at 0.1 units/kg/hour 2
- NEVER interrupt insulin infusion when glucose falls—instead add dextrose to prevent hypoglycemia while continuing insulin to clear ketosis 2
- Continue insulin until pH >7.3, bicarbonate ≥18 mEq/L, and anion gap ≤12 mEq/L regardless of glucose levels 2
- Transition to subcutaneous insulin 2-4 hours before stopping IV insulin to prevent rebound 4, 2
AKA:
- Insulin is NOT indicated and should NOT be given 1
- Ketosis resolves with fluid resuscitation and dextrose administration alone 1
Electrolyte Management
Both conditions: Monitor potassium closely as total body deficits are common 1, 2
EuDKA: Add 20-30 mEq/L potassium (2/3 KCl and 1/3 KPO₄) once renal function assured and K+ <5.3 mEq/L 2
AKA: Add 20-40 mEq/L potassium when levels fall below 5.5 mEq/L 1
Both conditions: Bicarbonate administration is generally NOT recommended as it does not improve outcomes 4, 1, 2
Monitoring Protocols
EuDKA:
- Check blood glucose every 1-2 hours 2
- Draw blood every 2-4 hours for electrolytes, glucose, BUN, creatinine, osmolality, and venous pH 2
- Follow venous pH and anion gap to monitor acidosis resolution 2
AKA:
- Draw blood every 2-4 hours for electrolytes, glucose, BUN, creatinine, and osmolality 1
- Monitor for cardiac arrhythmias from electrolyte imbalances 1
Common Pitfalls to Avoid
EuDKA-Specific Pitfalls
- Stopping insulin when glucose normalizes—this is the most dangerous error 2
- Inadequate carbohydrate administration alongside insulin perpetuates ketosis 2
- Relying on nitroprusside method which misses β-hydroxybutyrate 2
- Premature termination before complete ketosis resolution 2
AKA-Specific Pitfalls
- Misdiagnosing as DKA and inappropriately administering insulin 6
- Failing to recognize that elevated glucose (up to 328 mg/dL) can occur in AKA 6
- Not providing adequate dextrose-containing fluids as primary therapy 1
Resolution Criteria
EuDKA: Glucose stabilization, bicarbonate ≥18 mEq/L, pH >7.3, and anion gap ≤12 mEq/L 2
AKA: Clinical improvement with resolution of acidosis through fluid and electrolyte replacement alone 1, 6
Discharge Planning
Both conditions: Structured discharge plan with follow-up within 1-2 weeks if glucose control not optimal 4, 1
AKA-specific: Include alcohol cessation resources and education on AKA prevention 1, 6
EuDKA-specific: If SGLT2 inhibitor-related, discontinue medication and educate on risk factors 4, 7