Intraoperative Diagnosis of Sodium-Glucose Transporter-2 Inhibitor-Associated Euglycemic Diabetic Ketoacidosis

Sodium-glucose transporter 2 inhibitors (SGLT2i) are increasingly used in diabetic patients having cardiovascular and renal comorbidities. Despite their benefits for glucose control and reducing cardiovascular complications, they are not without risks. We present a case of euglycemic diabetic ketoacidosis (DKA) in a 60-year-old male with metastatic melanoma and type 2 diabetes mellitus (DM) on empagliflozin, undergoing craniotomy for brain tumor resection. Intraoperatively, high anion gap metabolic acidosis with normal blood sugar levels was observed, leading to the diagnosis of euglycemic DKA. Management included immediate initiation of intravenous insulin with dextrose, which was continued in the neuro-intensive care unit (NICU) postoperatively for three days. Euglycemic DKA is sometimes tricky to diagnose due to the absence of significant hyperglycemia as the name suggests, potentially delaying recognition by clinicians. Early detection, intravenous insulin with dextrose, correction of metabolic derangements, and discontinuation of SGLT2i are essential components of management. This case underscores the necessity of considering euglycemic DKA in SGLT2i-treated patients undergoing surgery, particularly when metabolic acidosis with a high anion gap is present despite normal blood glucose levels.