Euglycemic Diabetic Ketoacidosis Diagnosis and Management

Clinical Presentation

The American Diabetes Association notes that euglycemic diabetic ketoacidosis presents with nausea, vomiting, malaise, fatigue, abdominal pain, dyspnea, and altered mental status, despite blood glucose levels below 250 mg/dL, making it a diagnostic challenge that requires high clinical suspicion 1
Respiratory symptoms, such as dyspnea and Kussmaul respirations, may occur as the body attempts to compensate for metabolic acidosis 1
Abdominal pain is often present and can mimic acute abdominal pathology 1
Altered mental status, ranging from confusion to obtundation, though typically less severe than in hyperglycemic DKA, is a common symptom 2, 3

The FDA warns that patients treated with SGLT2 inhibitors are at risk of developing euglycemic DKA, and these medications should be discontinued 3-4 days before elective surgery to prevent this complication 1, 4

The American College of Emergency Physicians recommends intravenous fluid resuscitation with balanced electrolyte solutions at 15-20 mL/kg/h during the first hour, and insulin infusion at 0.1 U/kg/h after confirming potassium >3.3 mEq/L 6, 5
Blood glucose should be monitored every 1-2 hours until stable, and electrolytes, venous pH, and anion gap should be monitored every 2-4 hours 6, 5
Potassium replacement is necessary when levels fall below 5.5 mEq/L, and continuous cardiac monitoring is recommended in severe cases (pH <7.0) to detect arrhythmias from electrolyte shifts 5, 7
Treatment resolution criteria include glucose <200 mg/dL, serum bicarbonate ≥18 mEq/L, venous pH >7.3, and anion gap ≤12 mEq/L 5