Perioperative implications of sodium-glucose cotransporter-2 inhibitors: a case series of euglycemic diabetic ketoacidosis in three patients after cardiac surgery

Lau, Aaron; Bruce, Simon; Wang, Erica; Ree, Ron; Rondi, Kevin; Chau, Anthony

doi:10.1007/s12630-017-1018-6

Cited by 46 publications

(43 citation statements)

References 13 publications

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“…With regard to changes in insulin management, preoperative dose reductions were reported in two cases, 17,36 omission before surgery in one, 19 postoperative dose reduction in one, 36 and postoperative omission in four. 17,22,37 One case described an interruption without specifying whether this occurred before or after operation. 26 Among the aforementioned cases, five underwent bariatric surgery.…”

Section: Perioperative Handling Of Sodium-glucose Cotrasnporter-2 Inhmentioning

confidence: 99%

Perioperative diabetic ketoacidosis associated with sodium-glucose co-transporter-2 inhibitors: a systematic review

Thiruvenkatarajan

Meyer

Nanjappa

et al. 2019

British Journal of Anaesthesia

112

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Background: Perioperative diabetic ketoacidosis (DKA) with near-normal blood glucose concentrations, termed euglycaemic ketoacidosis (EDKA), is an adverse effect associated with sodium-glucose co-transporter-2 inhibitors (SGLT2i). Guidelines are still evolving concerning the perioperative management of patients on SGLT2i. We performed a systematic review of published reports of DKA from SGLT2i in the surgical setting to understand better the clinical presentation and characteristics of SGLT2i-associated DKA. Methods: We searched PubMed, Embase, and ProQuest for reports of perioperative DKA involving SGLT2i up to January 2019. Results: Forty-two reports of EDKA and five cases of hyperglycaemic diabetic ketoacidosis (HDKA) were identified from 33 publications. Canagliflozin was implicated in 26 cases. Presentation time varied from a few hours up to 6 weeks after operation. Precipitating factors may include diabetes medication changes, diet modifications, and intercurrent illnesses. There were 13 cases (12 EDKA and one HDKA) of bariatric surgery, 10 of them noted very-low-calorie diet regimes as a precipitating factor. No precise association between interruption of SGLT2i and the occurrence of DKA could be identified. Seven patients required mechanical ventilation, and acute kidney injury was noted in five. Five cases needed imaging to rule out anastomotic leak and pulmonary embolism, all of them revealed negative findings. Outcome data were available in 32 cases, all of them recovered completely. Conclusions: EDKA is likely to be under-recognised because of its atypical presentation and may delay the diagnosis. Understanding this clinical entity, vigilance towards monitoring plasma/capillary ketones helps in early identification and assists in the management.

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Section: Perioperative Handling Of Sodium-glucose Cotrasnporter-2 Inhmentioning

confidence: 99%

Perioperative diabetic ketoacidosis associated with sodium-glucose co-transporter-2 inhibitors: a systematic review

Thiruvenkatarajan

Meyer

Nanjappa

et al. 2019

British Journal of Anaesthesia

112

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“…These results are consistent with the main trial population. Importantly, perioperative use of SGLT2 inhibitors is still controversial, given the risk of euglycemic diabetic ketoacidosis, a rare but potentially severe complication (74). Regarding GLP1 receptor agonists, small studies suggest improved glycemic control and cardiovascular safety when used in the perioperative period of CABG (75,76).…”

Section: New Glucose-lowering Drugsmentioning

confidence: 99%

Weighing Coronary Revascularization Options in Patients With Type 2 Diabetes Mellitus

Tavares

Farkouh

2020

Canadian Journal of Diabetes

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Key MessagesPatients with diabetes mellitus more frequently have diffuse and multivessel coronary artery disease. Coronary artery bypass surgery is the preferred revascularization strategy in most patients with diabetes. Special attention should be given to optimal control of risk factors in the postrevascularization setting. a b s t r a c t Patients with diabetes mellitus (DM) are at increased risk for developing coronary artery disease. Choosing the optimal revascularization strategy, such as coronary artery bypass grafting or percutaneous coronary intervention (PCI), may be difficult in this population. A large body of evidence suggests that, for patients with DM and stable multivessel ischemic heart disease, coronary artery bypass grafting is usually superior to PCI, leading to lower rates of all-cause mortality, myocardial infarction and repeat revascularization in the long term. In patients with less complex coronary anatomy (2-or single-vessel disease, especially without involvement of the proximal left anterior descendent artery), PCI may be a viable option. Because these anatomic patterns are less frequent in patients with DM, there is less evidence to guide revascularization in these cases. Patients with DM and left main disease and those in the acute coronary syndrome setting are also underrepresented in randomized trials, and the best revascularization strategy for these patients is not clear. Once the revascularization procedure is performed, patients should be kept engaged in controlling the risk factors for progression of cardiovascular disease. Avoidance of smoking, control of cholesterol, blood pressure and glycemic levels; regular practice of physical activity of at least moderate intensity; and a balanced diet are of key importance in the postrevascularization period. In this study, we review the current literature in the management of patients with DM and coronary artery disease undergoing a revascularization procedure.Ó 2019 Canadian Diabetes Association. Mots clés : maladie cardiovasculaire pontage aortocoronarien diabète intervention coronarienne percutanée r é s u m é Les patients atteints de diabète sucré (DS) sont exposés à un risque accru de coronaropathie. Le choix d'une stratégie de revascularisation optimale telle que le pontage aortocoronarien ou l'intervention coronarienne percutanée (ICP) peut être difficile pour cette population. De nombreuses données probantes montrent que chez les patients atteints de DS et d'une cardiopathie ischémique multitronculaire stable le pontage aortocoronarien offre généralement des résultats supérieurs à l'ICP, puisqu'il entraîne une diminution des taux de mortalité toutes causes confondues et de revascularisation répétée à long terme. Chez les patients qui ont une anatomie des artères coronaires moins complexe (maladie monotronculaire ou bitronculaire, particulièrement sans la contribution de l'artère interventriculaire Can J Diabetes 44 (2020) 78e85antérieure proximale), l'ICP peut être une option viable. Comme ces anatomies sont moins fréquentes c...

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“…Although there are no formal UK guidelines at the time of writing, SGLT‐2 inhibitors should be stopped 2–3 days before surgery due to the risk of euglycaemic ketoacidosis. If this is not possible, blood ketones should be monitored in addition to blood glucose . If the patient usually takes a long‐acting subcutaneous insulin, this may be continued at 80% of the normal dose together with i.v.…”

Section: Optimising the Patient's Conditionmentioning

confidence: 99%

Pre‐optimisation of patients undergoing emergency laparotomy: a review of best practice

Poulton¹,

Murray

2019

Anaesthesia

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Summary Although the concept of pre‐operative optimisation is traditionally applied to elective surgery, there is ample opportunity to apply similar principles to patients undergoing emergency laparotomy. The key challenge is achieving meaningful improvements in a patient's condition without introducing delays to time‐sensitive surgery, which may be required in a matter of hours. Optimisation can be considered in two parts: that of the patient's condition; and that of the care pathway. Optimising the patient's condition is less about improving long‐term pathology, and more about correcting physiological derangement, such as electrolyte and fluid balance, blood loss, prompt treatment of sepsis, and ensuring appropriate continuation of medication in the peri‐operative period. Optimising the care pathway involves ensuring that the system is designed to deliver reliably the appropriate interventions, such as prompt antibiotics, and access to computed tomography scanning and the operating theatre with minimal delay.

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Perioperative implications of sodium-glucose cotransporter-2 inhibitors: a case series of euglycemic diabetic ketoacidosis in three patients after cardiac surgery

Cited by 46 publications

References 13 publications

Perioperative diabetic ketoacidosis associated with sodium-glucose co-transporter-2 inhibitors: a systematic review

Perioperative diabetic ketoacidosis associated with sodium-glucose co-transporter-2 inhibitors: a systematic review

Weighing Coronary Revascularization Options in Patients With Type 2 Diabetes Mellitus

Pre‐optimisation of patients undergoing emergency laparotomy: a review of best practice

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