SUN-558 - Developing A Tailored Protocol for Euglycemic Diabetic Ketoacidosis, A Quality Improvement Project

Diabetic ketoacidosis (DKA) is a serious complication of diabetes, characterized by hyperglycemia, metabolic acidosis, and ketosis. With increasing use of sodium–glucose cotransporter-2 inhibitors (SGLT2i), there has been a rise in euglycemic DKA (euDKA), defined by ketoacidosis with normal or only mildly elevated blood glucose (BG). The distinct pathophysiology of euDKA requires modifications to the standard DKA management approach.

Most hospitals use standardized DKA protocols, and in the absence of a dedicated euDKA pathway, patients with euDKA are frequently managed using the same DKA protocol by default. At our institution, the DKA protocol prioritizes aggressive IV fluid resuscitation, with volumes approaching 9L in the first 24 hours. Insulin titration is primarily guided by hyperglycemia, targeting an initial glucose range of 180-250 mg/dL, which may be suboptimal when glucose elevations are modest. Furthermore, patients treated with SGLT2i frequently have comorbid heart failure and chronic kidney disease, placing them at increased risk for volume overload during high-volume fluid resuscitation.

To address these limitations, we developed a modified euDKA protocol that was implemented at a community hospital in October 2025. It emphasizes lower target glucose ranges (100–180 mg/dL) on our software-guided insulin dosing tool, along with the minimum required fluid resuscitation per the ADA DKA guidelines. These changes aim to better align with euDKA physiology by optimizing IV insulin dosing and reducing adverse events related to fluid overload. We hope for this protocol to aid in patient safety while effectively treating the underlying ketosis.

In this study, we present the first phase of Plan–Do–Study–Act (PDSA) framework. We analyzed patients admitted with euDKA over 12 months preceding the implementation of the euDKA protocol. Sixty-two admissions met criteria for euDKA. Most patients had type 2 diabetes (74%), followed by type 1 diabetes (24%); 61% were male and 39% female. Median age was 60 years. SGLT2i and GLP-1 receptor agonist use was documented in 18.3%. Median BG on admission was 203.5 mg/dL. Hemoglobin A1c was 8% and median level of plasma beta-hydroxybutyrate was 3.6 mmol/L. Hospitalizations were complicated by CHF exacerbation and/or pulmonary edema in 8% of cases. 73% of the patients had a positive net balance upon discharge, with a median net fluid of +1.84 L. The median length of stay was 8.76 days.

Ongoing PDSA evaluation will compare this baseline cohort with the post-implementation cohort after 12 months of protocol use to assess whether a modified euDKA protocol reduces CHF exacerbations and pulmonary edema, improves fluid balance, shortens length of stay, and enhances overall hospital outcomes. Through this project, we propose that a tailored euDKA protocol more effectively addresses the pathophysiology of euDKA and supports safer inpatient management.

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