Management of Euglycemic Diabetic Ketoacidosis

Diagnosis and Initial Assessment

The diagnostic criteria for euDKA include arterial pH <7.3, serum bicarbonate <15 mEq/L, presence of ketonemia/ketonuria, and blood glucose that may be normal or only mildly elevated 2
Laboratory evaluation should include plasma glucose, blood urea nitrogen/creatinine, serum ketones, electrolytes with calculated anion gap, osmolality, urinalysis, arterial blood gases, complete blood count, and electrocardiogram 2, 3
Direct measurement of β-hydroxybutyrate in blood is preferred over nitroprusside method, which only measures acetoacetic acid and acetone 2, 3

Begin with isotonic saline (0.9% NaCl) at 15-20 mL/kg/hour during the first hour 4, 2, 1
Continue aggressive fluid management to restore circulatory volume and improve tissue perfusion 1
Add dextrose-containing fluids (5% dextrose with 0.45-0.75% NaCl) earlier in treatment to maintain adequate glucose levels while continuing insulin therapy to clear ketosis 2, 1

Start continuous intravenous regular insulin infusion at 0.1 units/kg/hour without an initial bolus 2, 3
Continue insulin infusion until resolution of ketoacidosis (pH >7.3, serum bicarbonate ≥18 mEq/L, and anion gap ≤12 mEq/L) regardless of glucose levels 2, 1
Never interrupt insulin infusion when glucose levels fall; instead, add dextrose to prevent hypoglycemia while continuing insulin to clear ketosis 2, 3

Monitor potassium levels closely, as insulin therapy and correction of acidosis can cause hypokalemia 2, 3
Include 20-30 mEq/L potassium (2/3 KCl and 1/3 KPO₄) in the infusion once renal function is assured and serum potassium is <5.3 mEq/L 4, 2
Maintain serum potassium between 4-5 mmol/L throughout treatment 2, 3
Bicarbonate administration is generally not recommended for patients with pH >6.9 2, 1, 3

Check blood glucose every 1-2 hours 3
Draw blood every 2-4 hours to determine serum electrolytes, glucose, blood urea nitrogen, creatinine, osmolality, and venous pH 2, 3
Follow venous pH and anion gap to monitor resolution of acidosis 2, 3

DKA resolution requires: glucose stabilization, serum bicarbonate ≥18 mEq/L, venous pH >7.3, and anion gap ≤12 mEq/L 2, 3
When transitioning to subcutaneous insulin, administer basal insulin 2-4 hours before stopping the intravenous insulin to prevent recurrence of ketoacidosis 5, 1, 3
Administration of a low dose of basal insulin analog in addition to intravenous insulin infusion may prevent rebound hyperglycemia 5, 1

Premature termination of insulin therapy before complete resolution of ketosis 2, 3
Inadequate carbohydrate administration alongside insulin in euDKA, which can perpetuate ketosis 1
Interruption of insulin infusion when glucose levels fall without adding dextrose 2, 3
Inadequate monitoring and replacement of electrolytes, particularly potassium 2
Relying solely on nitroprusside method to measure ketones, which doesn't detect β-hydroxybutyrate, the predominant ketone body in DKA 2, 3