Euglycaemic ketoacidosis: a potential new hazard to plastic surgery day case and inpatient procedures

A woman aged 44 underwent elective standard abdominoplasty and bilateral mastopexy (superiorly based pedicle with vertical scar) following weight loss of 8.5 stone (53.9 kg) over a 5-year period. She had type 2 diabetes and her antidiabetic medications included metformin, liraglutide and empagliflozin. Towards the end of the first postoperative day, she reported gradual onset of nausea, vomiting and abdominal pain. Her condition continued to deteriorate overnight, becoming tachycardic and tachypnoeic. Urgent investigations showed severe diabetic ketoacidosis with euglycaemia. She was managed with fluid resuscitation, insulin infusion and intravenous sodium bicarbonate in the high dependency unit. She made a complete clinical and biochemical recovery and was discharged on day 9 postoperatively. This case illustrates a diagnostic challenge of a serious life-threatening complication of diabetes in the postoperative period associated with a novel class of antidiabetic medications, sodium-glucose cotransporter 2 inhibitors.