Euglycaemic diabetic ketoacidosis and its risk factors in patients undergoing coronary artery bypass grafting surgery: a single-centre nested case-control study in China

• Published in: BMJ Open
• Main Authors: Xi Chen, Hui Zheng, Congchao Lu, Yifan Liu, Rui Hu, Nai-jun Tang, Mengli Yang, Hongya Xing, Kerui Dai, Jiyin Li
• Format: Article
• Language: English
• Published: BMJ Publishing Group 2025-08-01
• Online Access: https://bmjopen.bmj.com/content/15/8/e098758.full

Objectives This study examines the incidence and risk factors of euglycaemic diabetic ketoacidosis (euDKA) in patients undergoing coronary artery bypass grafting (CABG) and evaluates their postoperative outcomes over a 6-month follow-up period.Design This study is a single-centre, nested case-control study, conducted in Tianjin, China.Setting An international cardiovascular hospital.Participants A total of 1524 patients, with a mean age of 64 (9) years, who underwent isolated elective CABG surgery were reviewed.Primary and secondary outcome measures Data were extracted from electronic medical records. EuDKA cases were identified by reviewing laboratory examination results until discharge, including arterial blood gas analysis and urine samples. Logistic regression analysis was used in a case-control design to identify potential risk factors of sodium-glucose cotransporter 2 inhibitor (SGLT2i)-associated euDKA. Post-discharge follow-up was conducted through regular outpatient visits.Results 15 patients with euDKA, all with type 2 diabetes, were identified post-surgery, 13 of whom were SGLT2i users. The cumulative incidence of euDKA within 7 days after surgery was 1% in the cohort, increasing to 7.6% among those who discontinued SGLT2i 1–6 days (n=171) before surgery. A case-control study added seven additional confirmed euDKA patients to the case group, resulting in 20 cases and 95 controls. Univariate regression analysis revealed that the risk of euDKA was 7.304 times higher (95% CI 2.517 to 21.197; p<0.001) for patients who took their last dose within 3 days prior to surgery compared with patients who discontinued SGLT2i 3–6 days before surgery. During the intraoperative period, pH <7.35 (OR: 7.017, 95% CI 1.849 to 26.638; p=0.004) and blood glucose <10 mmol L−1 (OR: 6.882, 95% CI 1.822 to 25.997; p=0.004) were associated with a higher risk of euDKA. Compared with controls, euDKA patients experienced a higher rate of type 5 myocardial infarction (6/20 (30%) vs 9/95 (9.5%); p=0.035) and recurrent ketosis post-discharge (3/19 (15.8%) vs 0/87 (0%); p=0.005).Conclusions This cohort study highlights a notable incidence of euDKA following CABG, particularly among patients using SGLT2i. Close monitoring in the ICU is recommended for patients with intraoperative abnormal blood glucose and pH levels to prevent euDKA.