Hidden risk of euglycemic diabetic ketoacidosis with sodium-glucose cotransporter 2 (SGLT2) inhibitors in emergency general surgery in the United States: a case report
Abstract
Understanding empagliflozin use during the perioperative period is crucial for improving outcomes, given the increasing use of sodium-glucose cotransporter 2 (SGLT2) inhibitors and the growing population of surgical patients with diabetes. A 62-year-old woman with poorly controlled type 2 diabetes (hemoglobin A1c, 11.9%), obesity, coronary artery disease, and prior euglycemic diabetic ketoacidosis (euDKA) was taking empagliflozin and insulin when she presented with acute cholecystitis. Initial evaluation demonstrated tachypnea and mild metabolic acidosis with near-normal glucose levels. While kept nothing by mouth and resuscitated with normal saline and sliding-scale insulin, she developed severe high–anion-gap metabolic acidosis (pH, 7.1) with marked ketosis and mild hyperglycemia within 6 hours, consistent with euDKA, requiring intensive care. Treatment with intravenous insulin, dextrose-containing fluids, and bi-carbonate resolved the anion gap by hospital day 3, permitting an uncomplicated laparoscopic cholecystectomy. On postoperative day 1, euDKA recurred (pH, 7.2; glucose, 76 mg/dL) and responded to the same protocol with endocrinology-guided insulin adjustment. In urgent surgical settings, clinicians should discontinue SGLT2 inhibitors immediately, initiate early glucose-containing fluids and insulin therapy, and monitor ketones and acid-base status—even in the setting of normal glucose—to prevent delayed diagnosis. Increased awareness may assist providers who manage…
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