(263) Management Trends of Euglycemic Diabetic Ketoacidosis in the Intensive Care Unit

Introduction: Euglycemic diabetic ketoacidosis (eDKA) is characterized by anion gap metabolic acidosis, ketosis, and normoglycemia. Limited guidance exists regarding appropriate treatment strategies, given its etiology which differs from traditional DKA. Current institutional management involves a fixed rate insulin infusion with a dextrose infusion titrated to normoglycemia. This study aims to describe the trends of eDKA treatment strategies and elucidate optimal management.

Methods: This is a retrospective, observational study conducted at Northwestern Memorial Hospital including patients in any ICU with a diagnosis of eDKA from October 2020 to October 2022. Endpoints include adherence to a fixed dose insulin infusion, ICU length of stay, time to anion gap closure, recurrence of eDKA during admission, and time to and appropriate transition off insulin infusion. Safety endpoints include hypoglycemic events (blood glucose < 70 mg/dL or administration of a 25 g dextrose IV push or glucagon per institutional hypoglycemia protocol), and hypokalemic events (serum potassium < 3.3 mEq/L.)

Results: Fifteen patients met inclusion criteria. The median starting insulin rate was 0.09 units(u)/kg/hour(hr) (IQR 0.05-0.1 u/kg/hr.) Most patients were initiated on a concomitant dextrose-containing maintenance fluid. The median time to anion gap closure was 10.6 hours (hrs) (IQR 6.9 – 20.4) and the median insulin infusion duration was 31.8 hrs (IQR 19.6 – 56.6.) Compared to titratable insulin infusions, the four patients treated with a fixed rate insulin infusion had a shorter median time to anion gap closure (8 vs. 13.9 hrs), median ICU length of stay (48.4 vs. 79.5 hrs), time to subcutaneous insulin transition (30.4 vs. 63.1 hrs), and duration of insulin infusion (27.2 vs. 31.9 hrs.) There were 14 and 25 instances of hypoglycemia and hypokalemia, respectively, only one of which necessitated need for stopping the infusion.

Conclusions: A fixed dose of 0.1 u/kg/hr is a safe, effective strategy for managing eDKA. It should be continued for the duration of SGLT2 inhibitor washout, regardless of time to anion gap closure. This strategy necessitates a concomitant titratable dextrose-containing fluid to maintain normoglycemia.