Diagnostic and Management Pitfalls of SGLT2 Inhibitor-Associated Ketoacidosis in the ICU: Lessons Following Cardiac Surgery and GLP-1 Agonist Interaction.

Sodium-glucose cotransporter 2 inhibitors (SGLT2i) are cornerstones in the treatment of Type 2 diabetes (T2D), but their use is associated with diabetic ketoacidosis (DKA), a potentially life-threatening complication in the critical care setting. We present two cases of male patients with T2D who developed SGLT2i-associated ketoacidosis under different stressors: the first following coronary artery bypass graft (CABG) surgery and the second after the addition of semaglutide to his therapeutic regimen. Both patients presented with high anion gap metabolic acidosis, ketonuria, and plasma glucose levels < 200 mg/dL. Management required intravenous insulin protocols and glucose supplementation to reverse ketosis. This report emphasizes the need for preoperative suspension protocols and close monitoring of changes in combination therapy to avoid diagnostic delays in the intensive care unit.