Anesthesia Incident Reporting System (AIRS) Case 2022-12: Knowledge is Power, But How to Keep Up?

ASA Monitor December 2022, Vol. 86, 19–20

By: Brent Lee, MD, MPH, FASA and Madina Gerasimov, MD

A 76-year-old male was found to have multiple episodes of ventricular tachycardia at a community hospital. He was started on a lidocaine infusion and transferred to a tertiary care hospital for an emergent cardiac ablation.

Previous medical history included congestive heart failure secondary to non-ischemic cardiomyopathy with an ejection fraction of 20%, atrial fibrillation, and hypertension.

Preoperative medications included aspirin, sacubitril/valsartan (Entresto), and dapagliflozin (Farxiga).

Upon admission to the cardiac ICU and prior to the procedure, all his home medications were continued, and the patient was made NPO. The patient was evaluated by the on-call anesthesiologist and appeared to be ill, tachypneic, and complained of abdominal pain and nausea. The critical care team decided to delay the procedure until the following day.

In the EPS lab the next day, the patient again appeared ill and was still tachypneic, but cardiology determined that the procedure could no longer be delayed. The decision was made to proceed with the cardiac ablation.

Sedation was initiated by a different anesthesiologist. However, due to the tachypneic spontaneous ventilation that appeared to interfere with the cardiac ablation, the case was converted to a general anesthetic with endotracheal intubation and an arterial line was placed.

The results of an initial arterial blood gas analysis were consistent with severe metabolic acidosis with compensatory respiratory alkalosis. The base deficit was 12.8mEq/L and the serum glucose level was normal (88 mg/dL).

The astute anesthesiologist, upon further reflection on the patient’s medical history and puzzling clinical presentation, determined that the metabolic acidosis was due to euglycemic diabetic ketoacidosis (EDKA) secondary to dapagliflozin, a sodium-glucose co-transporter-2 inhibitor (SGLT-2 inhibitor), administered in a stressed and fasting patient.

Intravenous dextrose, insulin, and fluids were administered, resulting in an improvement of the patient’s acid/base status. Urinalysis concurrently demonstrated ketonuria and glucosuria consistent with the presumptive diagnosis of EDKA. The endocrinology service was consulted upon the patient’s return to the ICU and the dapagliflozin was discontinued. The patient’s condition improved rapidly, and the patient was discharged to home the following day.

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