Sodium-glucose cotransporter-2 (SGLT2) inhibitors have revolutionized treatment for type 2 diabetes, heart failure, and chronic kidney disease—but they're creating new challenges for anesthesia professionals. With more patients on these medications heading to surgery, understanding their unique perioperative risks has never been more critical.At the heart of this issue lies euglycemic ketoacidosis—a potentially life-threatening complication that's particularly insidious because it lacks the classic hyperglycemia that would normally trigger suspicion. We dive deep into the latest evidence, revealing that patients on SGLT2 inhibitors have an increased risk of developing postoperative ketoacidosis compared to those not taking these medications, with significantly worse outcomes when complications occur.We present a practical algorithm for risk stratification, considering factors like procedure duration, anesthesia type, diabetes control, and comorbidities. You'll learn which patients should hold their medication, which can proceed with caution, and what monitoring strategies to implement when patients haven't properly discontinued their medication before surgery. This guidance is especially valuable for emergency cases where postponement isn't an option.Whether you're developing institutional protocols or making decisions for individual patients, this episode equips you with the knowledge to navigate the complexities of SGLT2 inhibitor management in the perioperative period. Subscribe to stay informed about the latest in anesthesia patient safety and join our mission to ensure no one is harmed by anesthesia care.For show notes & transcript, visit our episode page at apsf.org: https://www.apsf.org/podcast/257-sweet-trouble-perioperative-management-of-sglt2-inhibitors/© 2025, The Anesthesia Patient Safety Foundation

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