The use of sodium-glucose cotransporter 2 (SGLT2) inhibitors is increasingly common in type
2 diabetes mellitus (DM) management. Patients taking an SGLT2 inhibitor are at increased risk for euglycemic
diabetic ketoacidosis (EDKA). We report an intraoperative diagnosis of EDKA in a patient taking an SGLT2 inhibitor. The
patient was found to have an arterial pH of 7.21 and serum beta-hydroxybutyrate of 88.8 mg/
dL (normal: <3.0 mg/dL) with serum glucose <250 mg/dL. Acidosis resolved with insulin and
glucose infusions. Perioperative specialists must recognize the potential for EDKA in patients
taking SGLT2 inhibitors. Expert opinion suggests preoperative cessation for 2–3 days and
intraoperative serum ketone concentration measurement for at-risk patients.