Recommended Citation
Hussain H, Park A. SGLT-2 inhibitor-induced euglycemic diabetic ketoacidosis: A case report. Presented at: Midwest Anesthesia Residents Conference (MARC); April 26, 2025; Indianapolis, IN.
Presentation Notes
Presented at: Midwest Anesthesia Residents Conference (MARC); April 26, 2025; Indianapolis, IN.
Abstract
Introduction: Euglycemic diabetic ketoacidosis (eDKA) is a rare but potentially life-threatening complication of sodium-glucose cotransporter-2 (SGLT-2) inhibitors, such as empagliflozin (Jardiance). The incidence of eDKA is rising with increasing use of SGLT-2 inhibitors. Unlike traditional DKA, eDKA is characterized by significant ketoacidosis with normal to only mildly elevated blood glucose levels, making it a diagnostic challenge. The mechanisms underlying eDKA include increased glucagon secretion, enhanced lipolysis, and reduced insulin secretion, all of which promote ketogenesis despite euglycemia. Surgery, prolonged fasting, and critical illness further exacerbate this metabolic state. Here, we present a case of a 79-year-old female with type 2 diabetes mellitus (T2DM) who developed eDKA following preoperative use of empagliflozin and underwent urgent surgery for a femoral fracture. This case highlights the importance of recognizing eDKA in perioperative patients on SGLT-2 inhibitors and underscores the need for early diagnosis and aggressive management. Case Presentation: A 79-year-old female with a history of type 2 diabetes mellitus (T2DM) presented to the ED after a mechanical fall, reporting right hip pain. She had last taken empagliflozin the day prior. Found to have a subtrochanteric femur fracture, she underwent urgent intramedullary nailing under general anesthesia. Intraoperative baseline arterial blood gas (ABG) revealed a pH of 7.09, bicarbonate 11, pCOâ‚‚ 37, glucose 173 mg/dL, potassium 4.3, lactic acid 1.6, and an anion gap (AG) of 27. Given concern for eDKA, she received aggressive IV fluid boluses, 100 mEq bicarbonate and 500 cc albumin. Subsequent ABG improved to pH 7.24, pCOâ‚‚ 33, bicarbonate 14, glucose 159 mg/dL, potassium 3.9, and AG 21. Postoperatively, the patient was transferred to the ICU. Urinalysis revealed ketonuria, and serum beta-hydroxybutyrate was elevated at 4.6 mmol/L. She was treated with IV fluids, D5W and an insulin infusion, with progressive closure of the anion gap over three days. Her metabolic status improved, and she was transferred to acute inpatient rehabilitation. Conclusion: While SGLT-2 inhibitors offer significant benefits for patients with T2DM, this case emphasizes their potential to precipitate eDKA in the perioperative setting. Delayed recognition of eDKA can lead to worsening acidosis and metabolic instability, which may adversely impact surgical and postoperative outcomes. Clinicians should maintain a high index of suspicion for eDKA in patients taking SGLT-2 inhibitors, especially in those undergoing surgery or experiencing physiologic stress. Early identification, prompt initiation of fluid resuscitation, insulin therapy, and close hemodynamic monitoring are crucial for successful management. This case also reinforces the importance of holding SGLT-2 inhibitors in the perioperative period for at least 3 days prior to surgery to mitigate the risk of eDKA. 1. Erica Chow et al. (2023) 11: e003666. 2. Plewa, M. C. (2023). Euglycemic diabetic ketoacidosis. StatPearls 3. Nasa, Prashant et al. (2021) World Journal of Diabetes 12: 514-523.
Type
Oral/Podium Presentation
Affiliations
Advocate Illinois Masonic Medical Center