UMEM Educational Pearls - By Cody Couperus-Mashewske

Title: Euglycemic DKA Pitfalls and Pearls

Keywords: Euglycemic DKA (PubMed Search)

Posted: 8/20/2024 by Cody Couperus-Mashewske, MD
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Euglycemic DKA (eDKA) is a medical emergency requiring prompt attention. It is caused by an imbalance of insulin and glucagon leading to ketone accumulation (1-3). In addition to typical risk factors for DKA, those for eDKA include SGLT-2 inhibitor use and pregnancy, with 30% of DKA cases in pregnancy presenting euglycemic (4, 5).

eDKA presents with an anion gap metabolic acidosis, ketosis/ketonuria, & blood glucose less than 250 mg/dL.

Diagnosis requires ruling out other causes of anion gap metabolic acidosis, including toxic ingestions.

The cornerstone of eDKA management is ensuring enough dextrose to allow needed insulin administration to reverse ketone accumulation.

Pitfalls

Not giving enough insulin to reverse ketosis due to concern about low blood sugars
Not giving enough dextrose to support sufficient insulin dosing
Not uptitrating insulin for refractory acidosis caused by eDKA

Pearls

Start insulin with at least 0.05 units/kg/hour along with IV dextrose (3,5,7,9)
Start IV dextrose at 5-10 g/hr (9). This will be 100-200 mL/hr of a 5% dextrose solution (dextrose should be added to either normal or ½ normal saline to avoid causing hyponatremia!)
- Dextrose concentrations: D5 = 50 g/L || D10 = 100 g/L || D20 = 200 g/L
Euglycemic DKA may present WITHOUT ketonuria if the patient is on an SGLT-2 inhibitor (7,8) – send a beta hydroxybutyrate!
eDKA is most common in the first two months of SGLT-2 inhibitor use, but can happen at any time (6)

UMEM Educational Pearls - By Cody Couperus-Mashewske

Title: Euglycemic DKA Pitfalls and Pearls

Pitfalls

Pearls

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