Hidden risk of euglycemic diabetic ketoacidosis with sodium-glucose cotransporter 2 (SGLT2) inhibitors in emergency general surgery in the United States: a case report

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 bicarbonate 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 such patients and may reduce complications and morbidity in the acute care setting.