(363) Empagliflozin-Induced Euglycemic Ketoacidosis in Patients Undergoing Cardiac Surgery

Introduction: Anion Gap (AG) metabolic acidosis (MA) in patients (pts) undergoing cardiac surgery (CS) is typically a result of a low cardiac output state & in the absence of hypovolemia, hypothermia, acute kidney injury or hyperglycemia warrants ruling out catastrophes including cardiac tamponade, cardiac dysfunction & mesenteric ischemia. Empagliflozin is a sodium-glucose co-transporter-2 (SGLT2) inhibitor used in the management of diabetes & heart failure with reduced ejection fraction & can give rise to profound euglycemic AG ketoacidosis (KA). Lack of awareness of this side effect can give rise to delays in treatment, prolonging length of stay (LOS) & a waste of resources for ruling out other causes of AG MA.

Methods: Our study was conducted at the 12-bed Cardiothoracic Intensive Care Unit within the Department of Cardiothoracic Surgery at a busy tertiary center. Our center performs over 1000 CS per year.
We conducted a retrospective analysis of 12 pts identified with euglycemic (EKA) over a span of 6 months between January & June 2022.
We analyzed the type of offending SGLT-2 inhibitor, time to ordering the beta-hydroxybutyrate test & accurately diagnosing the cause of MA in these patients, ICU LOS & mortality.

Results: 7 patients underwent off-pump coronary artery bypass graft (CABG) surgery , 3 patients underwent on- pump CABG & 2 patients underwent complex aortic surgeries. The average AG was 17 and the average negative base excess was –5.2
All patients had a normal lactate level ruling out a low flow state. 6 patients required emergent transthoracic echo-cardiograms to rule out cardiac tamponade. Time to diagnosing EKA was more than 12 hours post-operatively in these patients. 3 patients required re-insertion of their arterial catheters for safe monitoring of the anion gaps. The average ICU LOS in these patients was 2.4 days; 1.1 day higher than the average LOS in the CTS ICU. All of the patients were treated with hydration & insulin infusions & were safely discharged home.

Conclusions: Empagliflozin induced EKA is a significant challenge in patients undergoing cardiac surgery causing a waste of resources and a prolonged ICU LOS. Clinicians need to be aware of this side-effect & diagnose & treat early besides advising pts to withhold these agents 3-5 days prior to planned surgery.