What is the immediate management for a patient presenting with euglycemic diabetic ketoacidosis (DKA)?

Immediate Management of Euglycemic Diabetic Ketoacidosis

For euglycemic DKA, initiate aggressive isotonic saline resuscitation at 15-20 mL/kg/hour, start continuous IV insulin at 0.1 units/kg/hour (after excluding hypokalemia), and add dextrose-containing fluids early to prevent hypoglycemia while continuing insulin until ketoacidosis resolves. 1

Critical Initial Steps

Fluid Resuscitation (First Priority)

• Begin with isotonic saline (0.9% NaCl) at 15-20 mL/kg/hour (approximately 1-1.5 L in the first hour) to restore circulatory volume and tissue perfusion 1, 2
• Continue aggressive fluid replacement throughout treatment, as inadequate fluid resuscitation can worsen both the ketoacidosis and any underlying precipitating condition like pancreatitis 1

Electrolyte Assessment Before Insulin

• Check serum potassium immediately—if K+ <3.3 mEq/L, delay insulin therapy and aggressively replace potassium first to prevent life-threatening cardiac arrhythmias 2
• Once K+ ≥3.3 mEq/L, add 20-30 mEq/L potassium (2/3 KCl and 1/3 KPO₄) to IV fluids once adequate urine output is confirmed 2, 3
• Target serum potassium of 4-5 mEq/L throughout treatment 2

Insulin Therapy

• Start continuous IV insulin infusion at 0.1 units/kg/hour (approximately 5-7 units/hour) without an initial bolus 1, 3
• This is the standard of care for critically ill or mentally obtunded patients 1, 2
• Monitor blood glucose every 1-2 hours 3

The Euglycemic DKA Difference: Early Dextrose Addition

The critical distinction in euglycemic DKA management is that dextrose-containing fluids must be added much earlier than in typical DKA 1, 4:

• Since glucose levels are already near-normal (<250 mg/dL by definition), add 5% dextrose with 0.45-0.75% NaCl to IV fluids early in treatment 2
• Continue insulin infusion despite normal glucose levels until ketoacidosis resolves—this is essential and a common pitfall to avoid 1, 5
• The dextrose prevents hypoglycemia while allowing continued insulin therapy to suppress ketogenesis 4
• Inadequate carbohydrate administration alongside insulin in euglycemic DKA perpetuates ketosis 1

Monitoring Parameters

Check every 2-4 hours 1, 2:

• Serum electrolytes (particularly potassium, sodium, phosphate)
• Venous pH and anion gap
• Blood glucose
• β-hydroxybutyrate (preferred method for monitoring ketone resolution) 1, 2

Resolution Criteria

Continue treatment until ALL of the following are met 1, 2:

• pH >7.3
• Serum bicarbonate ≥18 mEq/L
• Anion gap ≤12 mEq/L
• Clinical symptom improvement

Note that glucose targets are less relevant in euglycemic DKA—focus on resolution of acidosis and ketosis 1

What NOT to Do

• Do not administer bicarbonate unless pH <6.9-7.0, as it provides no benefit and may worsen ketosis, cause hypokalemia, and increase cerebral edema risk 1, 2
• Do not stop insulin when glucose normalizes—premature discontinuation before complete ketosis resolution leads to DKA recurrence 1, 2
• Do not forget to identify and treat the precipitating cause (infection, pancreatitis, SGLT2 inhibitor use, starvation, insulin pump failure) concurrently 1, 6, 7

Transition to Subcutaneous Insulin

• When ketoacidosis resolves, administer basal insulin (intermediate or long-acting) 2-4 hours BEFORE stopping IV insulin to prevent recurrence 1, 2
• This overlap period is essential to prevent rebound ketoacidosis 2

Special Consideration: SGLT2 Inhibitors

If the patient is on SGLT2 inhibitors (a common cause of euglycemic DKA), discontinue immediately and do not restart for 3-4 days before any planned surgery 2, 6, 4