Aaron Lau1, Simon Bruce2,3, Erica Wang4, Ron Ree2,3, Kevin Rondi2,3, Anthony Chau2,3. 1. Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, BC, Canada. aaron.lau@medportal.ca. 2. Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, BC, Canada. 3. Department of Anesthesiology, St. Paul's Hospital, Vancouver, BC, Canada. 4. Department of Pharmacy, Faculty of Pharmaceutical Sciences, St. Paul's Hospital, University of British Columbia, Vancouver, BC, Canada.
Abstract
PURPOSE: Sodium-glucose cotransporter-2 inhibitors (SGLT2i) comprise the newest class of oral hypoglycemic agents approved for treating type II diabetes mellitus (DM-II). Their use, however, has been associated with the rare development of euglycemic diabetic ketoacidosis (euDKA). We present three cases of euDKA that occurred following elective coronary artery bypass grafting surgery. The role of the anesthesiologist in the prevention, diagnosis, and management of this complication is also discussed. CLINICAL FEATURES: Three patients receiving chronic SGLT2i therapy for DM-II (discontinued one to two days preoperatively) underwent cardiac surgery. On the first postoperative day, each exhibited nausea, vomiting, and tachypnea. Although these nonspecific postoperative findings are common, our patients also exhibited anion gap metabolic acidosis (pH < 7.3, anion gap > 12 mmol·L-1) with lower than anticipated serum glucose levels of < 14 mmol·L-1. Serum and urine ketone analyses confirmed a diagnosis of euDKA. After insulin and dextrose infusions were initiated, rapid resolution of the metabolic abnormalities occured. CONCLUSIONS: Anesthesiologists should recognize that patients receiving SGLT2i preoperatively are at risk of developing euDKA. Hence, based on the pharmacokinetics of SGLT2i, discontinuing the medication at least two days prior to surgery should minimize the risk. Diagnosing euDKA is challenging and often delayed because of its nonspecific signs and symptoms. When suspected, serum and urine ketones should be monitored to reduce the time to diagnosis and treatment.
PURPOSE:Sodium-glucose cotransporter-2 inhibitors (SGLT2i) comprise the newest class of oral hypoglycemic agents approved for treating type II diabetes mellitus (DM-II). Their use, however, has been associated with the rare development of euglycemic diabetic ketoacidosis (euDKA). We present three cases of euDKA that occurred following elective coronary artery bypass grafting surgery. The role of the anesthesiologist in the prevention, diagnosis, and management of this complication is also discussed. CLINICAL FEATURES: Three patients receiving chronic SGLT2i therapy for DM-II (discontinued one to two days preoperatively) underwent cardiac surgery. On the first postoperative day, each exhibited nausea, vomiting, and tachypnea. Although these nonspecific postoperative findings are common, our patients also exhibited anion gap metabolic acidosis (pH < 7.3, anion gap > 12 mmol·L-1) with lower than anticipated serum glucose levels of < 14 mmol·L-1. Serum and urine ketone analyses confirmed a diagnosis of euDKA. After insulin and dextrose infusions were initiated, rapid resolution of the metabolic abnormalities occured. CONCLUSIONS: Anesthesiologists should recognize that patients receiving SGLT2i preoperatively are at risk of developing euDKA. Hence, based on the pharmacokinetics of SGLT2i, discontinuing the medication at least two days prior to surgery should minimize the risk. Diagnosing euDKA is challenging and often delayed because of its nonspecific signs and symptoms. When suspected, serum and urine ketones should be monitored to reduce the time to diagnosis and treatment.
Authors: Siddhartha Dutta; Tarun Kumar; Surjit Singh; Sneha Ambwani; Jaykaran Charan; Shoban B Varthya Journal: J Family Med Prim Care Date: 2022-03-10