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Euglycemic DKA 





  • Major adverse event in T2DM (rarely T1) taking SGLT2 inhibitors

  • Triggered by:

    • intercurrent illness, surgery, fasting, reduced carbohydrate intake

  • SGLT2 inhibitors:

    • Lowers blood glucose by inhibiting renal glucose reabsorption

    • e.g. canagliflozin, dapagliflozin, empagliflozin


  • Timing: few hours to 6 wks post-op

  • Risk factors:

    • Reduced carb intake, volume depletion, concurrent illness, ↑ surgical stress, insulin being held, bariatric surgery, pregnancy

  • High degree of suspicion for serum/urine ketones

  • Signs:

    • Normoglycemia / moderate hyperglycemia

    • Metabolic acidosis with high anion gap

      • decreased serum HCO3

    • Ketonemia &/or ketonuria

  • Symptoms:

    • Excessive thirst / urination

    • Vomiting / dehydration / other sx of hypotension

    • Altered LOC

    • Weakness / tiredness / fatigue

    • Kussmaul respiration (deep, rapid)

  • Need to hold SGLT2i at least 24 hrs pre-op

  • Resume >24hrs post-operatively only when adequate PO intake




  • Avoid dexamethasone

  • Hold SGLT2i at least 24-48 hr pre-op

    • Resume 24-48hrs post-op assuming normal PO intake

  • Good post-op pain control

  • Maintain euvolemia



  • Thiruvenkatarajan V, Meyer EJ, Nanjappa N, Van Wijk RM, Jesudason D. Perioperative diabetic ketoacidosis associated with sodium-glucose co-transporter-2 inhibitors: a systematic review. Br J Anaesth. 2019 Jul;123(1):27-36. doi: 10.1016/j.bja.2019.03.028. Epub 2019 May 3. PMID: 31060732.

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