What is the treatment for a patient with euglycaemic diabetic ketoacidosis (DKA)?

Treatment of Euglycemic Diabetic Ketoacidosis

Core Treatment Principle

The treatment of euglycemic DKA follows the same fundamental principles as hyperglycemic DKA, but with one critical modification: dextrose-containing fluids must be administered alongside intravenous insulin from the outset to correct metabolic acidosis and ketonemia while preventing hypoglycemia. 1, 2

Initial Fluid Resuscitation

• Begin with aggressive 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, 3
• Unlike hyperglycemic DKA, you cannot wait for glucose to fall before adding dextrose—inadequate carbohydrate administration alongside insulin in euglycemic DKA will perpetuate ketosis 1
• Continue aggressive fluid replacement to restore estimated deficits within 24 hours 3

Insulin Therapy Protocol

• For critically ill or mentally obtunded patients, continuous intravenous regular insulin at 0.1 units/kg/hour is the standard of care 1, 3
• The key difference from hyperglycemic DKA: start 5% dextrose-containing fluids immediately with insulin infusion, not when glucose reaches 250 mg/dL 1, 2
• Monitor blood glucose every 2-4 hours and adjust insulin accordingly 1
• Continue insulin infusion until complete resolution of ketoacidosis (pH >7.3, serum bicarbonate ≥18 mEq/L, anion gap ≤12 mEq/L), regardless of glucose levels 3, 1

Critical Electrolyte Management

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

Bicarbonate Administration

• Bicarbonate is NOT recommended for pH >6.9-7.0, as multiple studies show no benefit in resolution time or outcomes, and it may worsen ketosis, cause hypokalemia, and increase cerebral edema risk 3, 1

Monitoring for Resolution

• Direct measurement of β-hydroxybutyrate in blood is the preferred method for monitoring ketoacidosis resolution 3, 1
• Resolution criteria: pH >7.3, serum bicarbonate ≥18 mEq/L, anion gap ≤12 mEq/L, and improvement in clinical symptoms 1
• Do not stop insulin based on glucose levels alone—continue until metabolic acidosis resolves 3, 1

Transition to Subcutaneous Insulin

• When DKA resolves and the patient can eat, administer basal insulin (glargine or detemir) 2-4 hours BEFORE stopping IV insulin infusion to prevent recurrence of ketoacidosis and rebound hyperglycemia 3, 1, 4
• Stopping IV insulin without prior basal insulin administration is the most common error leading to DKA recurrence 4
• Start a multiple-dose schedule using combination of short/rapid-acting and intermediate/long-acting insulin once patient tolerates oral intake 3, 4

Treatment of Underlying Cause

• Identify and treat precipitating factors concurrently: SGLT2 inhibitor use (most common in euglycemic DKA), infection, pancreatitis, pregnancy, fasting, insulin pump failure, or reduced food intake 1, 2, 5
• Discontinue SGLT2 inhibitors immediately and do not restart until 3-4 days after metabolic stability is achieved 3
• Obtain bacterial cultures and administer appropriate antibiotics if infection is suspected 3, 1

Common Pitfalls to Avoid

• Failure to recognize euglycemic DKA due to normal glucose levels—always check pH and ketones in ill diabetic patients regardless of blood glucose 2, 6, 7
• Inadequate fluid resuscitation worsens both DKA and any underlying condition like pancreatitis 1
• Premature discontinuation of insulin before complete resolution of ketosis leads to recurrence 3, 1
• Not adding dextrose early enough in euglycemic DKA perpetuates ketosis despite insulin therapy 1, 2
• Inadequate potassium monitoring and replacement can lead to fatal cardiac arrhythmias 3, 7