The effect of preoperative sodium-glucose cotransporter 2 inhibitors on the incidence of perioperative metabolic acidosis: A retrospective cohort study.

BACKGROUND: Sodium-glucose cotransporter 2 inhibitors are a novel class of anti-hyperglycemic agents. Although several cases of perioperative euglycemic diabetic ketoacidosis have been linked to these medications, the association remains unclear. This study aimed to examine the association between sodium-glucose cotransporter 2 inhibitor use and the incidence of perioperative metabolic acidosis with euglycemia, the surrogating outcome of perioperative euglycemic diabetic ketoacidosis. METHOD: This was a retrospective, matched cohort study, which was conducted in the intensive care unit of a tertiary care facility in Japan. We identified patients aged 20 years or older with diabetes mellitus who received pharmacologic therapy and were admitted to the intensive care unit after elective surgery between April 2014 and March 2019. We extracted the following data from the electronic medical record for matching: age, sex, surgery year, surgical site, hemoglobin A1c level, and prescription for sodium-glucose cotransporter 2 inhibitors. Eligible patients were divided into two groups, those who were prescribed sodium-glucose cotransporter 2 inhibitors (SGLT2-i group) and those who were not (control group). For each patient in the SGLT2-i group, we randomly selected four patients from the control group matched for the extracted characteristics. The primary outcome was the incidence of metabolic acidosis with an elevated anion gap and euglycemia. The secondary outcome was the lowest pH value of each patient during their ICU stay. RESULTS: A total of 155 patients were included in this study. Patients receiving sodium-glucose cotransporter 2 inhibitors had comparable characteristics to control participants; however, the proportions of patients undergoing dialysis were not similar. Metabolic acidosis with euglycemia was seen in 7/31 (22.6%) patients receiving sodium-glucose cotransporter 2 inhibitors and in 10/124 (8.1%) control patients (p = 0.047). CONCLUSIONS: This study shows that the use of sodium-glucose cotransporter 2 inhibitors is associated with a significantly higher incidence of metabolic acidosis with euglycemia. Patients receiving sodium-glucose cotransporter 2 inhibitors who are scheduled to undergo invasive surgical procedures should be closely monitored for the development of euglycemic diabetic ketoacidosis.

Hematopoietic Stem Cell Transplant in Facilities Without Intensive Care Units in Japan.

OBJECTIVES: Substantial numbers of patients after hematopoietic stem cell transplant need critical care. In Japan, however, data regarding the availability of an intensive care unit and intensivists at hospitals performing hematopoietic stem cell transplant are lacking. We aimed to investigate this issue using data from the 2014 Hematopoietic Cell Transplantation in Japan Annual Report of Nationwide Survey. MATERIALS AND METHODS: We examined whether hospitals have intensive care unit facilities and whether these hospitals are authorized by the Japanese Society of Intensive Care Medicine to provide intensivist training. The number of hematopoietic cell transplantations at each hospital was collected from the Transplant Registry Unified Management Program by the Japanese Data Center for Hematopoietic Cell Transplantation. RESULTS: Among 236 hospitals that perform hematopoietic stem cell transplants, 106 hospitals did not have intensive care units certified by the Japanese Society of Intensive Care Medicine. In patients who receive hematopoietic stem cell transplants with the highest mortality rate, 947 allogeneic transplants were performed at hospitals without this certification and 73 were performed at hospitals without intensive care units. CONCLUSIONS: We found that a considerable number of hematopoietic stem cell transplants are performed at hospitals with insufficient availability of critical care facilities or physicians.

Successful repeat ECMO in a patient with AIDS and ARDS.

Veno-venous extracorporeal membrane oxygenation (ECMO) is being more commonly used in patients with acute respiratory distress syndrome (ARDS) due to potentially reversible illnesses. Survival from ARDS using ECMO has been reported even in patients with AIDS. However, the indications for ECMO for ARDS due to immune reconstitution inflammatory syndrome (IRIS) in patients with AIDS are unknown. A 23-year-old man with AIDS and Pneumocystis jirovecii pneumonia was admitted to the intensive care unit with severe ARDS refractory to mechanical ventilator support requiring ECMO. Although ECMO was discontinued, a second treatment with ECMO was necessary due to IRIS-associated ARDS, resulting in an excellent patient outcome. This patient's clinical course suggests two important messages. First, ECMO is a reasonable option for the treatment of patients with ARDS even in a patient with AIDS. Second, ECMO may be effective for the treatment of patients with IRIS.