Perioperative euglycemic DKA: The YIN and YANG of sodium-glucose cotransporter 2 inhibitors.

Sodium-glucose cotransporter 2 inhibitors are gaining widespread acceptance in managing diabetic patients due to their favorable cardiac and renal protective effects. However, these drugs can cause a lethal complication described as sodium-glucose cotransporter 2 inhibitor-associated perioperative ketoacidosis (SAPKA) if they are continued until surgery. The FDA recommends stopping these medications at least 4-6 days before surgery to avoid the risk of euglycemic ketoacidosis, which can present a diagnostic challenge for perioperative physicians. We present three patients undergoing colorectal cancer surgeries who on SGLT2 inhibitors developed perioperative SGLT2i-associated perioperative ketoacidosis.