Perioperative Diabetic Ketoacidosis in Type 2 Diabetes: Risk and Prevention in the Era of SGLT2 Inhibitors

Diabetic ketoacidosis (DKA) typically affects patients with type 1 diabetes but can also occur in type 2 diabetes under severe stress or relative insulin deficiency. The postoperative phase constitutes a high-risk interval for diabetic ketoacidosis in individuals with type 2 diabetes, attributable to surgical stress, altered medication routines, and metabolic changes. The introduction of sodium-glucose cotransporter-2 (SGLT2) inhibitors has added complexity, as these medications can precipitate euglycemic DKA where ketoacidosis occurs without marked hyperglycemia. This review examines postoperative DKA in type 2 diabetes, focusing on pathophysiology, clinical outcomes, prevention strategies, and management approaches. The pathophysiology involves insulin deficiency, counterregulatory hormone excess, and SGLT2 inhibitor effects that promote ketogenesis. Risk factors include emergency surgery, poor glycemic control, insulin-dependent status, and SGLT2 inhibitor use. Prevention strategies include optimizing preoperative glycemic control, discontinuing SGLT2 inhibitors at least 3 days before surgery, maintaining basal insulin during the perioperative period, and monitoring for ketosis. Management requires aggressive fluid resuscitation, insulin therapy, electrolyte management, and addressing any precipitating factors. Early recognition is essential, particularly for euglycemic DKA which may be overlooked due to near-normal blood glucose levels. With proper preventive measures and timely management, most cases of postoperative DKA in type 2 diabetes can be avoided or successfully treated.