Case Series: Perioperative Euglycemic Diabetic Ketoacidosis in Bariatric Surgery
DOI:
https://doi.org/10.70422/m4307f76Keywords:
Surgery, Euglycemic diabetic ketoacidosis, Case Report, Diabetes, SGLT2, SGLT2 Inhibitor, Sodium-Glucose Cotransporter-2 Inhibitor, Sodium-Glucose Cotransporter-2, Euglycemic Diabetic Ketoacidosis, euDKA, Anesthesia, Bariatric SurgeryAbstract
Background: Euglycemic diabetic ketoacidosis (euDKA) is a rare but serious complication of diabetes management, particularly in patients treated with sodium-glucose co-transporter 2 (SGLT2) inhibitors. Postoperative patients, especially those undergoing bariatric surgery, are at elevated risk due to perioperative fasting, stress, and variable nutritional intake. This case series highlights three occurrences of euDKA in the immediate perioperative period.
Case Presentation: Three patients who underwent sleeve gastrectomy or Roux-en-Y gastric bypass developed euDKA within three weeks of procedure. One case occurred intraoperatively, and two presented postoperatively with nausea, vomiting, and metabolic acidosis. Each patient had recently been on SGLT2 inhibitors (empagliflozin or dapagliflozin), with variable drug cessation intervals before surgery. All were managed with insulin infusion, IV fluids, and supportive care, with full resolution of acidosis.
Discussion: Our case series highlights the variability in presentation of euDKA in the perioperative setting for bariatric surgery patients. Despite differences in the timing of SGLT2 inhibitor cessation and reinitiation, each patient developed euDKA within a narrow postoperative window, including one case detected intra-operatively before symptoms emerged. This variability suggests that current recommendations for withholding SGLT2 inhibitors may not fully account for the metabolic stress and abrupt nutritional changes surrounding bariatric surgery. Recognition therefore depends not only on adherence to medication guidelines, but on anticipation that euDKA may arise even when these guidelines are followed.
Conclusion: Bariatric surgery patients remain vulnerable to euDKA despite preoperative cessation of SGLT2 inhibitors. These cases highlight that euDKA is not solely a medication management issue, but a systems challenge that spans surgical care, nutrition, and metabolic oversight. Protocols that integrate preoperative cessation, postoperative monitoring, and cautious reinitiation of SGLT2 inhibitors will be essential to reduce risk.
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