Unmasking of SGLT2 inhibitor associated ketoacidosis after initiation of mechanical ventilation with consecutive cardiopulmonary resuscitation and extracorporeal life support

Sodium-glucose cotransporter 2 inhibitors (SGLT2i) are widely used for the treatment of type 2 diabetes, heart failure and chronic kidney disease due to their proven cardiovascular and renal benefits. However, they carry the risk of SGLT2i associated ketoacidosis, a rare but potentially life-threatening complication that can present without marked hyperglycaemia, often leading to delayed recognition. Although guidelines currently recommend discontinuing SGLT2i perioperatively and during acute illness, recent retrospective studies have questioned this approach, suggesting that perioperative continuation may not increase the incidence of SGLT2i associated ketoacidosis and could improve outcomes. While this trend is acknowledged, the present case highlights the dangers of continuing SGLT2i therapy in the intensive care setting with a special focus on the initiation of mechanical ventilation and underscores the need for an individualised management.