# Sodium glucose co-transporter 2 inhibitor-associated euglycaemic diabetic ketoacidosis in the emergency peri-operative period: a systematic review

## TL;DR

This study reviews cases of a rare but dangerous condition called euglycaemic diabetic ketoacidosis linked to a diabetes drug used before emergency surgeries.

## Contribution

The paper systematically reviews 30 cases to identify risk factors and clinical features of EuDKA in emergency surgical settings.

## Key findings

- EuDKA typically occurred within three days after emergency surgery.
- Risk factors included poor diabetes control, major surgery, and inadequate drug withholding.
- Ten patients required intensive care, showing the condition's severity.

## Abstract

Perioperative euglycaemic diabetic ketoacidosis (EuDKA) is a rare but life-threatening complication associated with sodium-glucose co-transporter-2 inhibitors (SGLT2i). It is characterised by ketonaemia, acidosis, and normal serum glucose. Whilst guidelines advise withholding SGLT2i prior to elective surgery, limited guidance exists for emergency procedures. This systematic review aimed to describe EuDKA cases following emergency surgery, identify patient characteristics, and examine contributing risk factors. A search of electronic databases up to April 2024 identified 30 cases from 21 publications. In most cases, EuDKA onset occurred within three days postoperatively (range: intraoperative to 10 days). Reported risk factors included inadequate SGLT2i withholding time, poor glycaemic control, morbid obesity, major surgery, intercurrent illness, suboptimal intraoperative diabetes management, and delayed gastrointestinal absorption. Morbidity was significant: ten patients required intensive care, two required intubation and ventilation, two received dialysis, and one underwent exploratory laparotomy. No deaths were reported. Due to atypical biochemical findings and non-specific symptoms, EuDKA remains under-recognised. Clinicians are advised to maintain a high index of suspicion, ensure appropriate perioperative insulin management, conduct vigilant laboratory monitoring, and provide patient education to reduce the risk in emergency surgical settings.

The online version contains supplementary material available at 10.1007/s00540-025-03570-2.