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Euglycemic DKA Before Surgery: SGLT2 Anesthesia Case [ Case Discussion ](https://mdster.com/blog?category=case-discussion) Euglycemic DKA Before Surgery: SGLT2 Anesthesia Case ====================================================== A board-style perioperative case on recognizing and stabilizing SGLT2 inhibitor–associated ketoacidosis with normal glucose [ MDster Editorial Team ](https://mdster.com/about) · Jun 08, 2026 · 4 min read · 22 [ Reviewed by Dr. Ali Ragab, MBBCH, MSc, MCAI ](https://mdster.com/medical-reviewers/dr-ali-ragab) [Editorial Policy](https://mdster.com/editorial-policy) | [Corrections Policy](https://mdster.com/corrections) [ Board Review ](https://mdster.com/blog?tag=board-review) [ Perioperative Medicine ](https://mdster.com/blog?tag=perioperative-medicine) [ Anesthesiology ](https://mdster.com/blog?tag=anesthesiology) [ Case Discussion ](https://mdster.com/blog?tag=case-discussion) [ Diabetes ](https://mdster.com/blog?tag=diabetes) ![Euglycemic DKA Before Surgery: SGLT2 Anesthesia Case](https://mdster.com/storage/blog/images/euglycemic-dka-before-surgery-sglt2-anesthesia-case.jpg) Share this article Share this post On this page 1. [ The case that should stop the list ](#the-case-that-should-stop-the-list) 2. [ Why this is euglycemic DKA until proven otherwise ](#why-this-is-euglycemic-dka-until-proven-otherwise) 3. [ Investigations that matter before anesthesia ](#investigations-that-matter-before-anesthesia) 4. [ Immediate management in pre-op holding ](#immediate-management-in-pre-op-holding) 5. [ Prevention for the rescheduled surgery ](#prevention-for-the-rescheduled-surgery) 6. [ Key Points for Board Exams ](#key-points-for-board-exams) 7. [ Closing synthesis ](#closing-synthesis) 8. [ Frequently Asked Questions ](#blog-faqs) 9. [ References ](#references-heading) On this page 1. [ The case that should stop the list ](#the-case-that-should-stop-the-list) 2. [ Why this is euglycemic DKA until proven otherwise ](#why-this-is-euglycemic-dka-until-proven-otherwise) 3. [ Investigations that matter before anesthesia ](#investigations-that-matter-before-anesthesia) 4. [ Immediate management in pre-op holding ](#immediate-management-in-pre-op-holding) 5. [ Prevention for the rescheduled surgery ](#prevention-for-the-rescheduled-surgery) 6. [ Key Points for Board Exams ](#key-points-for-board-exams) 7. [ Closing synthesis ](#closing-synthesis) 8. [ Frequently Asked Questions ](#blog-faqs) 9. [ References ](#references-heading) A normal glucose in pre-op holding can be falsely reassuring. In this case, proceeding with elective pneumoperitoneum would convert a correctable metabolic problem into an intraoperative resuscitation. The case that should stop the list ---------------------------------- A 54-year-old man with T2DM, BMI 32 kg/m², hypertension, and planned laparoscopic ventral hernia repair took empagliflozin yesterday morning. He fasted overnight and now reports fatigue, nausea, and diffuse abdominal pain. Glucose is 142 mg/dL, but VBG shows pH 7.28 and HCO3 14 mEq/L. Na is 138, Cl is 104, and K is 4.2. The anion gap is: `138 - (104 + 14) = 20 mEq/L` This is high anion gap metabolic acidosis with respiratory compensation. In a fasting surgical patient taking an SGLT2 inhibitor, euglycemic DKA moves to the top of the differential. Why this is euglycemic DKA until proven otherwise ------------------------------------------------- SGLT2 inhibitors promote glucosuria, lowering plasma glucose while reducing endogenous insulin secretion. Fasting, surgical stress, dehydration, and relative insulin deficiency then amplify lipolysis and hepatic ketogenesis. Consequently, the patient can be acidotic and ketotic without marked hyperglycemia. That mismatch is the trap. Key competing diagnoses remain important: - Starvation ketosis, usually with milder acidosis - Lactic acidosis, especially with shock, hypoperfusion, sepsis, or metformin accumulation - Uremic acidosis if renal function is impaired - Toxic alcohol ingestion when history or osmolar gap supports it - Sepsis or mesenteric pathology if abdominal findings evolve > Clinical Pearl: In an SGLT2 patient, nausea, abdominal pain, tachypnea, and anion gap acidosis outrank the glucose value. Investigations that matter before anesthesia -------------------------------------------- Do not chase the hernia explanation too quickly. Abdominal pain is common in DKA and can mimic surgical pathology. Order a focused metabolic workup: - Serum beta-hydroxybutyrate, preferred over urine ketones - Repeat BMP and VBG or ABG - Lactate, creatinine, BUN, and measured osmolality when indicated - Urinalysis for glucosuria and ketonuria, recognizing its limitations - ECG if potassium shifts or acidosis is significant Nitroprusside-based urine testing under-detects beta-hydroxybutyrate, the dominant ketone in DKA. For resolution, trend beta-hydroxybutyrate, anion gap, bicarbonate, pH, potassium, and clinical status. FindingInterpretationGlucose 142 mg/dLDoes not exclude DKAHCO3 14, pH 7.28Clinically meaningful metabolic acidosisAnion gap 20Ketones, lactate, renal failure, or toxins until sortedK 4.2Serum appears normal, but total body potassium may be depleted Immediate management in pre-op holding -------------------------------------- This elective case should be postponed. The anesthetic issue is not only acidosis; laparoscopy adds CO2 load, sympathetic stress, fasting, and postoperative nausea risk. Initial management is straightforward: 1. Cancel the elective procedure and notify surgery, endocrinology, and the perioperative medical team. 2. Stop the SGLT2 inhibitor. 3. Start balanced crystalloid, titrated to volume status. 4. Add dextrose-containing fluid early because insulin is required despite normal glucose. 5. Begin IV insulin infusion according to institutional DKA protocol. 6. Check potassium before insulin and replete aggressively as needed. If K is below 3.3 mEq/L, insulin is usually deferred until potassium is corrected. With K 3.3–5.2, potassium replacement typically accompanies insulin because serum potassium may fall rapidly. Balanced salt solutions are commonly preferred over 0.9% saline because large chloride loads can worsen hyperchloremic metabolic acidosis. This matters when anion gap closure and bicarbonate recovery are treatment targets. Prevention for the rescheduled surgery -------------------------------------- As of June 2026, ADA hospital standards and FDA labeling support withholding empagliflozin, canagliflozin, and dapagliflozin for at least 3 days before scheduled surgery; ertugliflozin is generally held for at least 4 days. The ADA also emphasizes restarting only after ketoacidosis risk factors have resolved. [\[1\]](#cite-1 "Reference [1]") Discharge instructions should be explicit, not simply “hold diabetes medications.” Tell the patient which drug, when to stop it, and what symptoms should trigger ketone testing. A practical plan: - Resume usual nutrition and hydration before considering SGLT2 restart. - Do not restart while vomiting, fasting, dehydrated, or ketotic. - Arrange diabetes or endocrinology input if glycemic bridging is needed. - For the next operation, document the last SGLT2 dose in the anesthesia record. - Advise blood ketone testing for nausea, vomiting, abdominal pain, or unexplained tachypnea even with normal glucose. Key Points for Board Exams -------------------------- - Euglycemic DKA is a high anion gap metabolic acidosis with ketosis and glucose that may be normal or only mildly elevated. - The anion gap here is 20 mEq/L. - Blood beta-hydroxybutyrate is the best ketone test for diagnosis and monitoring. - Elective surgery should be postponed until acidosis and ketosis resolve. - Treatment requires insulin plus dextrose, not dextrose avoidance. - Potassium must be checked and corrected before or during insulin therapy. - For US board-style answers, remember 3 days for empagliflozin, canagliflozin, and dapagliflozin; 4 days for ertugliflozin. Closing synthesis ----------------- The board-relevant move is recognizing that the glucose is a distractor. The anesthesiologist’s job is to identify the metabolic emergency, stop the elective pathway, and initiate DKA physiology-based treatment before induction. Frequently Asked Questions ---------------------------- ### Should elective surgery proceed if glucose is normal but anion gap acidosis is present? No. In a patient taking an SGLT2 inhibitor, high anion gap acidosis with compatible symptoms should prompt postponement and evaluation for euglycemic DKA. ### Why is dextrose given when the patient is not hypoglycemic? Dextrose permits continued insulin infusion, which suppresses lipolysis and ketogenesis. Without insulin, ketosis will persist despite normal glucose. ### What test best confirms and follows resolution of euglycemic DKA? Serum beta-hydroxybutyrate is preferred. Urine ketone tests may underrepresent the dominant ketone during DKA. ### When can the SGLT2 inhibitor be restarted after cancellation? Restart only after the patient is clinically well, eating and drinking normally, hydrated, and free of ketosis or acidosis. References (3) ------------------ 1. 1. [ American Diabetes Association. Standards of Care in Diabetes—2026: Diabetes Care in the Hospital. ](https://doi.org/10.2337/dc26-S016) [↩](#cite-ref-1-1 "Back to text") 2. 2. [ FDA. Jardiance prescribing information, including perioperative withholding guidance. ](https://www.accessdata.fda.gov/drugsatfda_docs/label/2025/204629s063lbl.pdf) 3. 3. [ FDA. Sodium-glucose Cotransporter-2 (SGLT2) Inhibitors safety information. ](https://www.fda.gov/drugs/postmarket-drug-safety-information-patients-and-providers/sodium-glucose-cotransporter-2-sglt2-inhibitors) Study pathway Build momentum in Anesthesiology with focused, exam‑style practice -------------------------------------------------------------------- - Airway, ventilation, and crisis drills - High‑yield anesthesia pharmacology made practical - Track weak topics and improve faster Free 5-day trial No credit card required. 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