# Situation: A 60-year-old man is admitted the day before an elective open abdominal operation under general anesthesia. He has type 2 diabetes mellitus and hypertension. He has no history of delayed gastric emptying, no gastrointestinal symptoms, and no known drug allergies. On the evening before surgery, the nurse reviews his medication history. Which finding should the nurse report to the surgeon and the anesthesia provider?

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> subject: Nursing Practice III — Care of Clients with Problems in Surgery, Oxygenation, Fluid and Electrolytes, Infectious, Inflammatory and Immunologic Response, Cellular Aberrations

## 문제

Situation: A 60-year-old man is admitted the day before an elective open abdominal operation under general anesthesia. He has type 2 diabetes mellitus and hypertension. He has no history of delayed gastric emptying, no gastrointestinal symptoms, and no known drug allergies.

On the evening before surgery, the nurse reviews his medication history. Which finding should the nurse report to the surgeon and the anesthesia provider?

## 보기

1. Took his last losartan yesterday morning
2. Took his last metformin with dinner tonight
3. Will take metoprolol tomorrow with a sip of water
4. Took his last ertugliflozin 3 days before surgery **✔ 정답**

**정답: 4**

## 해설

Sodium-glucose cotransporter 2 (SGLT2) inhibitors are held before surgery because of the risk of euglycemic ketoacidosis: 3 days for most drugs in the class, but 4 days for ertugliflozin. A last dose 3 days before surgery is one day short and must be reported. The other findings follow the usual rules for metformin, angiotensin receptor blockers, and beta blockers.

## 심화 해설

Perioperative medication safety: SGLT2 inhibitor hold time

The correct finding to report is option 4. This patient took his last dose of ertugliflozin only 3 days before surgery, but ertugliflozin requires a longer preoperative hold than most other SGLT2 inhibitors. The concern is not hypoglycemia or hyperglycemia; it is euglycemic diabetic ketoacidosis (EDKA), a dangerous metabolic state in which ketoacidosis develops even though blood glucose looks near-normal or only mildly elevated.

SGLT2 inhibitors promote urinary glucose loss and shift metabolism toward ketogenesis, so surgical fasting and stress can trigger ketoacidosis without marked hyperglycemia. Because the blood glucose may appear unremarkable, EDKA is easy to miss on routine postoperative checks. The perioperative risk is highest when the drug effect is still active during the fasting and stress of surgery.

The hold duration differs within the class. Most SGLT2 inhibitors—such as canagliflozin, dapagliflozin, and empagliflozin—are generally stopped 3 days before elective surgery. However, ertugliflozin requires a 4-day preoperative hold. A last dose taken 3 days before surgery is therefore one day short and must be reported to the surgeon and anesthesia provider so the team can adjust monitoring or consider rescheduling.

| Medication | Preoperative hold | Rationale |
| --- | --- | --- |
| Ertugliflozin | 4 days | Longer hold needed to reduce EDKA risk; last dose 3 days before surgery is insufficient |
| Most other SGLT2 inhibitors | 3 days | Standard class hold before elective surgery |
| Metformin | Withhold on day of surgery; last dose with dinner the night before is acceptable | Risk of lactic acidosis with renal hypoperfusion; short half-life allows evening dose |
| Losartan (ARB) | Often held morning of surgery; last dose yesterday morning is acceptable | Risk of intraoperative hypotension; no need for multi-day hold |
| Metoprolol (beta blocker) | Continue on day of surgery with a sip of water | Abrupt withdrawal risks rebound tachycardia and hypertension |

Watch out! EDKA can present with normal or only mildly elevated glucose, so relying on blood glucose alone will miss the diagnosis. Postoperative monitoring must include beta-hydroxybutyrate, anion gap, and bicarbonate when SGLT2 inhibitor exposure is recent or uncertain.

Key point! The hold time is drug-specific. Do not apply a uniform “3 days for all SGLT2 inhibitors” rule; ertugliflozin is the exception with a 4-day requirement.

The other options reflect standard perioperative practice and do not require reporting. Metformin taken with dinner the night before surgery is acceptable because it is held only on the day of surgery; its short half-life and the concern for lactic acidosis under intraoperative hypoperfusion do not require a longer preoperative washout. Losartan, an angiotensin receptor blocker, is often held the morning of surgery to reduce intraoperative hypotension, but a last dose the previous morning is not a safety concern. Metoprolol should be continued perioperatively, including on the morning of surgery with a sip of water, because abrupt beta blocker withdrawal can cause rebound tachycardia, hypertension, and myocardial ischemia.

The underlying mechanism of SGLT2 inhibitor-associated EDKA involves persistent urinary glucose excretion, which lowers plasma glucose and reduces insulin secretion. At the same time, the drug promotes a shift toward ketogenesis. When surgery adds fasting, dehydration, and stress hormones, the combination can produce ketoacidosis even at normal glucose levels [1][2]. The risk can persist beyond the nominal hold period in some patients, which is why clinical vigilance and ketone monitoring remain important even when the drug was stopped several days earlier [3]. A structured perioperative checklist for SGLT2 inhibitors emphasizes verifying the specific drug, the exact last dose date, and the planned monitoring for ketones and acid-base status [4].References (research sources)

- [1]Euglycemic Diabetic Ketoacidosis and Its Prevention in Elective Surgical Patients Taking Sodium-Glucose Linked Transporter 2 Inhibitors: An International Perspective.Research articleSelbie JHJ, Hiyama S, Pandit H. (2025) · DOI: 10.1016/j.artd.2025.101840

- [2]Beyond Glycemia: Pharmacology-Driven Ketogenesis and Euglycemic DKA with SGLT2 Inhibitors-A Practical Review for Acute Care.Research articleMeco M, Agosteo E, Zulli P, Nisi F, Giustiniano E. (2026) · DOI: 10.3390/jpm16030156

- [3]Risk of Euglycemic Diabetic Ketoacidosis Can Persist After Discontinuation of Sodium-glucose Cotransporter-2 Inhibitors.Research articleBobba SS, Campbell E, Bril F. (2025) · DOI: 10.1210/jcemcr/luaf268

- [4]The SGLT2 inhibitor checklist: a comprehensive review of perioperative and acute phase safety management.Research articleDeng B, Liu W, Chu Q. (2026) · DOI: 10.3389/fendo.2026.1777334

## 임상 시나리오

SGLT2 Inhibitor Preoperative HoldPreventing Euglycemic DKA in Elective Surgery
Hold ertugliflozin for 4 days before elective surgery; most other SGLT2 inhibitors require only 3 days.

The key risk is euglycemic diabetic ketoacidosis, which can occur with near-normal glucose and is easy to miss.

CautionA last ertugliflozin dose 3 days before surgery is one day short; report this to the surgeon and anesthesia provider for monitoring or rescheduling.

## 핵심 개념

- **Euglycemic diabetic ketoacidosis** — Ketoacidosis with near-normal blood glucose, a risk with SGLT2 inhibitors during fasting or surgical stress.
- **SGLT2 inhibitor** — Drug class promoting urinary glucose loss; held preoperatively to reduce ketoacidosis risk.
- **Ertugliflozin** — SGLT2 inhibitor requiring a 4-day preoperative hold, longer than the 3-day hold for most others.
- **Perioperative hold** — Stopping a medication before surgery to prevent complications such as ketoacidosis or bleeding.
- **Metformin** — Diabetes medication typically held the day of surgery but acceptable with dinner the night before.

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