Euglycemic DKA
Background
-
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
-
Considerations
-
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
Prevention
-
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
References
-
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.