Euglycemic diabetic ketoacidosis with gastrointestinal dysfunction following lung surgery in a patient on SGLT2...

Sodium-glucose cotransporter-2 inhibitors (SGLT2is) are associated with euglycemic diabetic ketoacidosis (EDKA), particularly in the perioperative setting. This report highlights EDKA complicated by postoperative gastrointestinal (GI) dysfunction following lung surgery.

A 42-year-old woman with type 2 diabetes managed with metformin and empagliflozin (SGLT2i) underwent video-assisted thoracoscopic right upper lobectomy for suspected early lung cancer. Empagliflozin was continued preoperatively. Postoperative day 2, she developed acute dyspnea, right lower abdominal pain (despite normal bowel movements), and tachycardia. Initial arterial blood gas (ABG) revealed severe metabolic acidosis (pH 7.022, HCO₃ ^- 4.9 mmol/L, base excess -24.4 mmol/L) without significant hyperglycemia (fasting glucose 6.23 mmol/L). Administration of 500 mL sodium bicarbonate yielded minimal improvement (pH 7.153). Abdominal computed tomography (CT) confirmed significant GI distension. Urinalysis on postoperative day 3 showed marked ketonuria (80 mg/dL) and glycosuria (2,000 mg/dL), confirming EDKA (β-hydroxybutyrate 8.11 mmol/L). Treatment involved intravenous insulin infusion (added to 5% glucose-saline with potassium), fluid resuscitation, and nutritional support, leading to resolution of symptoms and acidosis by postoperative day 5.

Postoperative GI distension in SGLT2i users may signal impending EDKA. Sodium bicarbonate monotherapy provided limited benefit. Successful management requires early recognition, cessation of SGLT2i, adequate caloric intake via dextrose-containing fluids, and insulin to suppress ketogenesis. Preoperative discontinuation of SGLT2i 3-4 days prior to surgery is strongly recommended.