Euglycemic diabetic ketoacidosis following sleeve gastrectomy in a patient with type 2 diabetes on a sodium-glucose co-transporter 2 inhibitor: a case report and call for practice guidelines.

BACKGROUND: Euglycemic diabetic ketoacidosis (eDKA) is associated with sodium-glucose co-transporter 2 inhibitor (SGLT2i) use in patients with type 2 diabetes (T2D) who are ketosis-prone because of factors such as acute illness and surgery. This report presents a case of eDKA that was admitted to the stepdown medical unit at an academic tertiary hospital following laparoscopic sleeve gastrectomy (LSG) and compares it with previous cases in the literature. The aim of this report is to describe the characteristics of eDKA presentation in LSG and identify measures to avoid such a preventable condition.

CASE DESCRIPTION: A 62-year-old woman with T2D on insulin and severe obesity with an initial body mass index of 55 kg/m2 underwent an uneventful LGS and was discharged on empagliflozin and metformin for glycemic control. She returned to hospital with nausea, vomiting, and an inability to tolerate oral intake and was found to have acute kidney injury, high anion gap metabolic acidosis, ketonuria, and glycosuria. However, her glucose level was normal, which prompted a diagnosis of eDKA after excluding surgical complications. She was discharged safely after she was placed back on an insulin-only regimen.

CONCLUSIONS: eDKA in patients who have undergone bariatric surgery may present with similar symptoms to post-bariatric surgical complications. This case emphasizes the need for clearer perioperative guidance.