Perioperative prevention of euglycaemic diabetic ketoacidosis in people living with type 2 diabetes established on sodium-glucose transport-2 inhibitors – a cross-site multi-cycle audit

• Postoperative ketone monitoring is important to prevent euglycaemic diabetic ketoacidosis in patients living with diabetes established on SGLT2 inhibitors. • Euglycaemic diabetic ketoacidosis events observed despite apparent normoglycaemia and protocol use. • Education improved preoperative cessation documentation rates. Sodium-glucose transport-2 (SGLT2) inhibitors are commonly prescribed for the management of type 2 diabetes mellitus, chronic kidney disease and heart failure. However, their continuation in the perioperative setting in people with diabetes can precipitate euglycaemic diabetic ketoacidosis (EDKA), a potentially life-threatening complication. This multi-cycle audit evaluated adherence to perioperative guidelines regarding preoperative cessation and postoperative re-initiation of SGLT2 inhibitors. Electronic health records of consecutive surgical patients with type 2 diabetes were reviewed over a 6-month period. Two cases of EDKA were identified. Targeted interventions – including staff education and dissemination of guidance – were implemented, followed by re-audit over a 4-month period. Documentation and perioperative SGLT2 inhibitor cessation improved significantly post-intervention; however, postoperative ketone monitoring remained suboptimal, and one further case of EDKA was identified. Since then, capillary blood ketone monitoring has been introduced in clinical areas. These findings add to the body of evidence on the perioperative use of SGLT2 inhibitors.