# Intraoperative Detection and Management of Euglycemic Ketonemia During Emergency Surgery Using Point-of-Care Blood Beta-Hydroxybutyrate Testing in a Patient Receiving Sodium-Glucose Cotransporter 2 (SGLT2) Inhibitors: A Case Report

## TL;DR

This case report describes a new intraoperative strategy using point-of-care testing to manage euglycemic ketonemia in a patient on SGLT2 inhibitors during emergency surgery.

## Contribution

A prototype intraoperative management regimen using point-of-care BHB testing for patients on SGLT2 inhibitors with insufficient drug withdrawal.

## Key findings

- The regimen enabled stable intraoperative metabolic control.
- Ketoacidosis was successfully prevented in an emergency surgical setting.

## Abstract

Patients who receive sodium-glucose cotransporter 2 inhibitors (SGLT2is) are at risk of developing euglycemic ketoacidosis (EDKA), particularly during the perioperative period, if drug withdrawal is insufficient. Although current guidelines recommend withholding SGLT2is prior to surgery, adequate withdrawal periods cannot always be ensured in emergency situations. However, to date, no standardized intraoperative management strategies have been established to address this risk in such situations. To address this gap, we developed a prototype intraoperative management regimen at our institution specifically for patients undergoing emergency surgery without sufficient SGLT2i withdrawal. This regimen was established on the basis of previously reported strategies for managing EDKA and included point-of-care blood beta-hydroxybutyrate (BHB) testing as a key intraoperative monitoring tool. In this case report, we describe the successful application of this regimen in an emergency surgical setting, resulting in stable intraoperative metabolic control without the development of ketoacidosis.