Sodium‐glucose linked transporter 2 inhibitor associated post‐operative euglycaemic diabetic ketoacidosis: an important consideration for all surgeons

Abstract

A 44-year-old male with type 2 diabetes mellitus presented with worsening nausea and vomiting day 3 post open right partial nephrectomy. His dapagliflozin (sodium-glucose linked transporter 2 inhibitor (SGLT2i)) was continued perioperatively. Initially, the patient recovered as expected; however, on day 3, he exhibited symptoms in keeping with post-operative ileus and was managed accordingly. Other than tachypnoea (respiratory rate 30), observations were unremarkable. Highest blood glucose level was 7.8 mmol/L. A blood gas revealed an acute metabolic acidosis (pH 7.28, bicarbonate 8 mmol/L, partial pressure of carbon dioxide 20 mmHg, base excess −15.1 mmol/L and anion gap 28 mmol/L) and the renal/endocrine team was consulted with a subsequent finding of a blood capillary ketone of 4.7 mmol/L. The patient was diagnosed with euglycaemic diabetic ketoacidosis (euDKA) on day 7. He was treated with standard DKA protocol and the patient normalized both symptomatically and biochemically within 12 h of initiation of treatment (Table 1). The patient was transitioned from intravenous to subcutaneous insulin, and was discharged day 11. The exact mechanism of euDKA caused by SGLT2i in perioperative patients is unknown. It may be associated with glucosuria blunting normal physiological stresses in surgical patients resulting in increased risk of lipolysis and ketogenesis. This mechanism results in normal or mildly elevated blood glucose levels which then masquerade the underlying DKA making recognition difficult. Multidisciplinary perioperative planning may be of benefit in surgical patients on an SGLT2i. euDKA requires a high index of suspicion and early detection with ketone testing may be appropriate. Standard DKA treatment can easily reverse this potentially lifethreatening condition. It is recommended that SGLT2i is ceased at least 3 days before an operation and restarted once the patient is eating and drinking. To the best of our knowledge, this is the first urological case reported in the literature. Reference