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Various toxicities: case report A 76-year-old man developed combined lactic and euglycemic diabetic ketoacidosis during treatment with dapagliflozin and metformin for type II diabetes mellitus. Additionally, he developed carcinoid crisis following off-label lidocaine intoxication. The man, with type II diabetes mellitus had been receiving oral metformin and dapagliflozin. Additionally, he had been receiving concomitant treatment with salbutamol. Subsequently, he was found to have a significant suspicion of pancreatic cancer, and he underwent a planned laparotomy. Alternatively, he received off-label lidocaine perfusor for perioperative pain management. Continuous medications with metformin and dapagliflozin were interrupted prior to surgery. Thereafter, he underwent a left-sided pancreatic resection with splenectomy and resection of the segment-III and colon adhesiolysis. General anaesthesia was performed in combination with a off-label lidocaine perfusor 1.5 mg/kg/hour for perioperative analgesia [not all dosages and routes stated]. He was minimally reliant on unspecified catecholamine, and the blood loss was managed. Following the surgical procedures, he developed increasing haemodynamic instability prior to extubation. The man received controlled ventilation. Subsequently, he had increasing narrow complex tachycardia and progressive metabolic acidosis. He was then transferred to ICU. On ICU admission, his blood gas analysis showed pH 7.230, base excess -8.5 mmol/L, glucose 167 mg/dL and lactate 3.4 mmol/L. Due to haemodynamic instability, lidocaine was discontinued. Given an increasing norepinephrine [noradrenaline] requirement, atrial flutter with 2:1 transfer by 135 /minute in ECG and increasing metabolic acidosis with satisfactory gas exchange, a medicinal and electrical cardioversion was carried out in a severe state of shock, during which a conversion in sinus tachycardia by 110 /minute occurred. A transthoracic echocardiography showed hypercontractile left ventricle and right ventricle function, most likely with volume depletion, along with higher grade tricuspid valve insufficiency. Thereafter, an increased lactic acidosis was observed despite massive volume supply with crystalloids, RBC concentrates and fresh frozen plasma and repeated buffering with sodium bicarbonate. His blood gas analysis revealed pH 7.225, base excess -7.2 mmol/L, glucose 212 mg/dL and lactate 9.6 mmol/L. Also, expanded haemodynamic monitoring showed cardiac index 3.5 L/min/m2, increased volume variability, decreased systemic resistance index and central venous oxygen saturation 79%. A urine status showed evidence of euglycemic diabetic ketoacidosis in combination with lactic acidosis (ketones 40 mg/dL, glucosuria >1.000 mg/dL and blood ketones 2.8 mmol/L), most likely to be an adverse event of a previous metformin and dapagliflozin therapy. Additionally, it was noted that the development of carcinoid crisis was associated with off-label lidocaine intoxication [time to reactions onsets not stated]. Subsequently, his blood gas a