How to manage diabetic ketoacidosis (DKA) with normal glucose levels?

Management of Diabetic Ketoacidosis with Normal Glucose Levels

When DKA presents with normal or near-normal glucose levels (euglycemic DKA), immediately start dextrose-containing IV fluids (D5 or D10) along with continuous insulin infusion to clear ketones, as insulin therapy must continue until metabolic acidosis resolves regardless of glucose levels. 1, 2

Recognition and Diagnosis

Euglycemic DKA is diagnosed when the classic DKA criteria are met—venous pH <7.3, serum bicarbonate <15 mEq/L, and moderate ketonuria or ketonemia—but blood glucose is <250 mg/dL or even normal. 3, 1

• Measure β-hydroxybutyrate directly rather than relying on urine ketones, as the nitroprusside method only detects acetoacetate and acetone, not the primary ketone body. 1
• Calculate the anion gap using [Na⁺] - ([Cl⁻] + [HCO₃⁻]); it should be >10-12 mEq/L in DKA. 1
• Common precipitating factors for euglycemic DKA include SGLT2 inhibitor use, pregnancy, starvation, alcohol use, and insulin pump failure with continued basal insulin. 4

Critical Management Principles

The fundamental principle is that insulin therapy must continue until ketoacidosis resolves (bicarbonate ≥18 mEq/L, venous pH >7.3, anion gap ≤12 mEq/L), not until glucose normalizes. 2, 5

Fluid and Dextrose Management

• Begin with isotonic saline (0.9% NaCl) at 15-20 mL/kg/hour during the first hour to restore intravascular volume. 3, 2
• Immediately add dextrose 5-10% to IV fluids when glucose is <250 mg/dL or already normal at presentation, while continuing insulin infusion. 2, 5
• This prevents hypoglycemia while allowing continued ketone clearance, which is the actual therapeutic target. 5

Insulin Therapy

• Start continuous IV regular insulin at 0.1 units/kg/hour without an initial bolus. 5
• Never stop insulin infusion based on glucose levels alone—continue until metabolic acidosis resolves. 2, 5
• Adjust dextrose concentration in IV fluids (increase to D10 or D12.5% if needed) to maintain glucose 150-200 mg/dL while continuing insulin. 5

Electrolyte Monitoring and Replacement

• Check potassium before starting insulin; total body potassium is depleted despite potentially normal or elevated initial levels due to acidosis. 2, 5
• Add 20-30 mEq/L potassium (2/3 KCl and 1/3 KPO₄) to IV fluids when serum potassium falls below 5.5 mEq/L. 2, 5
• Monitor electrolytes, glucose, and venous pH every 2-4 hours until stable. 5

Common Pitfalls to Avoid

• Do not discontinue insulin when glucose normalizes—this is the most critical error in euglycemic DKA management, as ketoacidosis will persist or worsen. 2, 5
• Do not rely solely on urine ketones for monitoring, as they can falsely suggest worsening ketosis during treatment when β-hydroxybutyrate is actually improving. 1
• Avoid overly rapid glucose correction; maintain glucose 150-200 mg/dL with dextrose-containing fluids throughout treatment. 5
• Do not use bicarbonate therapy unless pH <6.9, as it can worsen ketosis and increase cerebral edema risk. 4

Resolution Criteria

DKA is resolved when ALL of the following are met: 2, 5

• Serum bicarbonate ≥18 mEq/L
• Venous pH >7.3
• Anion gap ≤12 mEq/L
• Glucose <200 mg/dL (though this may already be achieved in euglycemic DKA)

Transition to Subcutaneous Insulin

• Administer basal subcutaneous insulin 2-4 hours before stopping IV insulin to prevent rebound hyperglycemia and ketoacidosis. 2
• British guidelines suggest using subcutaneous glargine along with IV insulin during DKA treatment, which has shown faster resolution and shorter hospital stays. 4