Euglycemic diabetic ketoacidosis with gastrointestinal dysfunction following lung surgery in a patient on SGLT2 inhibitor: a case report

Background: 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. Case Description: 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. Conclusions: 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.