Management of Euglycemic Diabetic Ketoacidosis
This patient does NOT have diabetic ketoacidosis despite the elevated beta-hydroxybutyrate, because the pH is normal (7.43) and bicarbonate is normal (28 mEq/L), which are incompatible with DKA diagnosis. 1, 2, 3
Why This Is Not DKA
DKA requires arterial pH <7.30, serum bicarbonate <18 mEq/L, and positive ketones - this patient has pH 7.43 and bicarbonate 28 mEq/L, both completely normal 1, 2, 3
The diagnostic criteria from the American Diabetes Association mandate blood glucose >250 mg/dL (present at 500 mg/dL), arterial pH <7.30 (absent - patient has 7.43), serum bicarbonate <18 mEq/L (absent - patient has 28 mEq/L), and presence of ketonemia 1, 2, 3
While beta-hydroxybutyrate of 10 mmol/L is markedly elevated (normal <0.5 mmol/L), ketosis without acidosis does not constitute ketoacidosis 4, 5
Appropriate Management Approach
Immediate Assessment
Verify the laboratory values - confirm pH, bicarbonate, and beta-hydroxybutyrate measurements are accurate, as this constellation (severe ketosis with normal acid-base status) is unusual 1, 2
Check anion gap - calculate anion gap to assess for any metabolic acidosis that might be masked by a concurrent metabolic alkalosis 1, 2, 3
Assess for SGLT2 inhibitor use - euglycemic DKA can occur with SGLT2 inhibitors, though this patient's glucose of 500 mg/dL argues against true euglycemic DKA 1, 2
Treatment Strategy
Administer insulin therapy to address hyperglycemia (blood glucose 500 mg/dL) and suppress ongoing ketogenesis, even though acidosis is absent 1, 2, 3
Provide intravenous fluids with isotonic saline to restore volume and improve tissue perfusion, which will help clear ketones 1, 2, 3
Monitor closely for development of acidosis - check venous pH and bicarbonate every 2-4 hours, as the patient could progress to true DKA if insulin deficiency worsens 1, 2, 3
Continue insulin until beta-hydroxybutyrate normalizes (<1.5 mmol/L indicates resolution of ketosis), even after glucose is controlled 5
Key Monitoring Parameters
Venous pH, bicarbonate, and anion gap every 2-4 hours to detect any progression to true DKA 1, 2, 3
Beta-hydroxybutyrate levels correlate better with ketosis resolution than urine ketones, which can remain positive even after blood ketones normalize 4, 6, 5
Serum potassium every 2-4 hours as insulin therapy drives potassium intracellularly and can cause life-threatening hypokalemia 1, 2, 3, 7
Critical Pitfall to Avoid
Do not treat this as full DKA with aggressive bicarbonate administration - bicarbonate is not indicated when pH >7.0, and this patient's pH is normal at 7.43 1, 2, 3
Do not delay insulin therapy waiting for acidosis to develop - the elevated beta-hydroxybutyrate and hyperglycemia require insulin treatment regardless of pH status 1, 2
Do not stop insulin when glucose reaches 250 mg/dL - add dextrose to IV fluids and continue insulin at reduced rate until beta-hydroxybutyrate normalizes to ensure complete ketosis resolution 1, 2, 3