Post-Operative Euglycemic Diabetic Ketoacidosis in a Patient With SGLT-2 Inhibitor Use and Recent Sleeve Gastrectomy

Area of Science:

• Endocrinology
• Metabolic Disorders
• Surgical Complications

Background:

• Type 2 diabetes mellitus management often involves multiple therapeutic agents, including insulin and sodium-glucose co-transporter-2 (SGLT-2) inhibitors.
• SGLT-2 inhibitors are associated with an increased risk of diabetic ketoacidosis (DKA), including the rare euglycemic form (euDKA).
• Surgical procedures represent significant physiological stressors that can precipitate metabolic derangements in diabetic patients.

Observation:

• A 51-year-old woman with type 2 diabetes mellitus experienced tachycardia on post-operative day 1 and altered mental status with tachypnea on post-operative day 2 following robotic-assisted sleeve gastrectomy.
• Her pre-operative medication regimen included an SGLT-2 inhibitor (Invokamet®) and a basal-bolus insulin regimen.
• Diagnosis of euDKA was confirmed by ketonuria and anion gap metabolic acidosis despite normal blood glucose levels.

Findings:

• The patient presented with euglycemic diabetic ketoacidosis (euDKA) in the post-operative period.
• The absence of significant hyperglycemia, a hallmark of typical DKA, complicated the initial diagnosis.
• Ketonuria in the context of anion gap metabolic acidosis was crucial for identifying euDKA.

Implications:

• Clinicians must maintain a high index of suspicion for euDKA in post-operative diabetic patients, especially those using SGLT-2 inhibitors.
• Awareness of euDKA is critical for timely diagnosis and management, preventing potentially severe complications.
• This case highlights the importance of considering medication side effects in the context of surgical stress when evaluating metabolic abnormalities.