Perioperative challenges in management of diabetic patients undergoing non-cardiac surgery

Abstract

Prediabetes and diabetes are important disease processes which have several perioperative implications. About one third of the United States population is considered to have prediabetes. The prevalence in surgical patients is even higher. This is due to the associated micro and macrovascular complications of diabetes that result in the need for subsequent surgical procedures. A careful preoperative evaluation of diabetic patients and patients at risk for prediabetes is essential to reduce perioperative mortality and morbidity. This preoperative evaluation involves an optimization of preoperative comorbidities. It also includes optimization of antidiabetic medication regimens, as the avoidance of unintentional hypoglycemic and hyperglycemic episodes during the perioperative period is crucial. The focus of the perioperative management is to ensure euglycemia and thus improve postoperative outcomes. Therefore, prolonged preoperative fasting should be avoided and close monitoring of blood glucose should be initiated and continued throughout surgery. This can be accomplished with either analysis in blood gas samples, venous phlebotomy or point-of-care testing. Although capillary and arterial whole blood glucose do not meet standard guidelines for glucose testing, they can still be used to guide insulin dosing in the operating room. Intraoperative glycemic control goals may vary slightly in different protocols but overall the guidelines suggest a glucose range in the operating room should be between 140 mg/dL to 180 mg/dL. When hyperglycemia is detected in the operating room, blood glucose management may be initiated with subcutaneous rapid-acting insulin, with intravenous infusion or boluses of regular insulin. Fluid and electrolyte management are other perioperative challenges. Notably diabetic ketoacidosis and hyperglycemic hyperosmolar nonketotic state are the two most serious acute metabolic complications of diabetes that must be recognized early and treated.

Position statement: surgery and diabetes mellitus (Update 2023)

“…Im Rahmen eines operativen Eingriffes kann es aufgrund der Auslenkung von antiinsulinär wirkenden endogenen Hormonen (Glukagon, Kortisol, Somatropin, Katecholamine) und des Auftretens von Entzündungsmediatoren im Rahmen der Akute-Phase-Reaktion zu einer Verschlechterung/Entgleisung einer diabetischen Stoffwechsellage kommen. Weiters kann eine Diabeteserkrankung unter diesen Umständen klinisch erstmanifestieren oder im Rahmen des präoperativen Evaluierens zufällig erstdiagnostiziert werden, weshalb die präoperative Evaluierung der glykämischen Stoffwechsellage relevant ist [6,7,9,[18][19][20]. Perioperative Hyperglykämie (> 140 mg/dl) ist bei Menschen mit und ohne Diabetes mellitus ein Risikofaktor für schlechtere postoperative Resultate und ist mit 20 bis 40 % bei allgemeinchirurgischen und 80 bis 90 % bei kardiochirurgischen Patient:innen häufig [21][22][23][24][25].…”

“…Erhöhte präoperative Blutzuckerwerte sind mit erhöhtem Risiko für postoperative Komplikationen assoziiert [38][39][40]. Daher sollten akute Blutzuckerentgleisungen mit Hyperglykämien über 300 mg/dl eine elektive Operation postponieren bis sich die Blutglukose zumindest für ein bis vier Stunden präoperativ im Zielbereich (zumindest < 180 mg/dl) befindet und Patient:innen metabolisch kompensiert sind [20,39,41].…”

Ligament Alteration in Diabetes Mellitus

“…A study conducted by Frisch et al reported the connection between DM in patients undergoing surgery and an elevated complication ratio due to the poor quality of soft tissues, followed by prolonged hospital stays and higher perioperative mortality [ 19 ].…”

“…Patients with DM, who do not have an impaired insulin secretion and are treated with a major surgery, have an even more exacerbated metabolic stress-related response for increased insulin demand. Major surgery provokes functional insulin insufficiency [ 20 ]; therefore, diabetic patients are at higher risk for a procedure-induced infection and poor glycaemic control [ 19 , 21 , 22 ].…”

Clinical challenges of glycemic control in the intensive care unit: A narrative review

“…Dysglycemia is common in patients admitted to the intensive care unit (ICU). Research over the past decades has established a multitude of adverse effects of altered glycemic control in patients having surgery and admitted to ICU[ 1 ]. From targeting euglycemia or tight glucose control in the early 2000’s, the focus has shifted to preventing hypoglycemia while maintaining moderate glycemic control.…”