Diabetes mellitus
Anesthetic relevance High
Anesthetic management Preoperative HgA1c value

Preoperative glucose value Preoperative medication adjustment Insulin administration

Post-operative glucose
Specialty Endocrine
Signs and symptoms Excessive thirst

Polyuria Polydypsia Glucosuria Peripheral neuropathy Ocular degeneration

Cardiovascular disease
Diagnosis HgA1c Fasting glucose
Treatment Oral anti-hyperglycemics Exogenous insulin administration

Diabetes is an endocrine, metabolic disorder marked by high levels of blood glucose. Three classifications of diabetics exist:

  1. Type 1 Diabetes, where an immune mediated destruction of pancreatic beta cells occurs causing a total reduction in endogenous insulin and thus causing hyperglycemia
  2. Type II Diabetes, where patients experience increasing insulin resistance for the level of endogenous insulin thus causing hyperglycemia
  3. Gestational Diabetes in which hyperglycemia occurs in the second or third trimester of pregnancy.

The diagnosis of diabetes is made based on fasting blood glucose levels and hemoglobin A1c levels. The diabetic population in the United States is both increasing in incidence and prevalence within the last decade. This disease affects multiple organ systems that have anesthetic implications including cardiovascular health, renal disease, peripheral neurologic function, and gastrointestinal emptying requiring preoperative optimization and intraoperative control.

Cystic fibrosis patients have an acquired form of diabetes as the most common co-morbidity of cystic fibrosis (20% of adolescents and 40-50% of adults).[1]

Anesthetic implications

Preoperative optimization

  • No overt indications for case cancellations for poorly controlled diabetes[2][3] except if patients are in diabetes ketoacidosis (DKA) or hyperosmolar osmotic non-ketotic crisis (HONK)
  • Postoperative blood glucose greater than 140 mg/dL is found in as many as 40% of patient undergoing non-cardiac surgery and almost 25% of those patients demonstrate a blood glucose greater than 180 mg/dL during the operative and immediate post-operative period[4][5]
  • Data shows mixed reduction of mortality with good blood glucose control in surgical patients[6], but a reduction in surgical site infection risk[7]
  • Consider case delay alongside surgery team if BG > 250 mg/dL and case is elective and a prothesis or synthetic biofilm will be inserted into the patient during surgery (i.e. prothesis, intraocular lens, joint replacement, graft, etc).
  • Obtain pre-operative HgA1c if one has not been obtained via primary care in last 3 months prior to surgery
    • If HgA1c > 8.0 - evidence shows greater incidence of post-operative hyperglycemia during patient recovery
Pre-operative medication adjustments:
Drug Class Medication Day before Surgery Day of surgery Notes
DPP-4 inhibitors Sitagliptin/Saxagliptin

lidagliptin/linagliptin

Take Take
Alpha-glucosidase

inhibitors

Acarbose/Miglitol Take Do not take
Sulfonylureas Glipizide/glyburide Take Do not take
SGLT-2 inhbitors dapagliflozin/canagliflozin

empagliflozin

Hold 3 days prior

to surgery[8]

Do not take Can cause euglycemic DKA[9] if not stopped in advance of surgery
SGLT-2 inhibitors ertugliflozin Hold 4 days prior

to surgery[8]

Do not take Can cause euglycemic DKA[9] if not stopped in advance of surgery
Biguanides metformin/Metformin ER Take +/- take Hold if patient has renal/hepatic insufficiency, COPD or CHF or if

team anticipates potential for AKI or hepatic shock during case

GLP-1 agonist exenatide/exenatide ER Take Do not take
GLP-1 agonist dulaglutide Take Do not take
GLP-1 agonist semaglutide Take Do not take
GLP-1 agonist liraglutide Take Do not take
Amylin mimetics pramlintide Take Do not take
Long acting insulin Glargine/detemir/degludec Take 80% of dose Take 80% of dose Coordinate with patient's endocrinologist
U-500 insulin Take usual dose Take 50% of dose Coordinate with patient's endocrinologist
70/30 insulin Take usual dose Change to NPH

and give 50% of dose

Coordinate with patient's endocrinologist
70/25 insulin Take usual dose Change to NPH

and give 50% of dose

Coordinate with patient's endocrinologist
50/50 insulin Take usual dose Change to NPH

and give 50% of dose

Coordinate with patient's endocrinologist
NPH insulin Take usual dose Take 50% of dose Coordinate with patient's endocrinologist
Prandial insulin Take usual mealtime dose Do not take Coordinate with patient's endocrinologist
Insulin pump Set at 80% basal rate Coordinate with patient's endocrinologist

Intraoperative management

Postoperative management

Related surgical procedures

Pathophysiology

Signs and symptoms

Diagnosis

Diagnosis of diabetes can be made by a variety of ways:

  1. Fasting plasma glucose ≥ 126mg/dL
  2. Two-hour plasma glucose ≥ 200mg/dL
  3. A1C ≥ 6.5 prior to initiating anti-hyperglycemic medications

Treatment

Medication

Surgery

Prognosis

Epidemiology

The diabetic population in the United States is both increasing in incidence and prevalence within the last decade. According to the 2017 National Diabetes Statistics Report from the Center for Disease Control (CDC), 10.5% of the U.S. population has diabetes with an estimated 21.4% of those who have the disease are still not diagnosed.[10]

References

  1. Association, American Diabetes (2021-01-01). "2. Classification and Diagnosis of Diabetes: Standards of Medical Care in Diabetes—2021". Diabetes Care. 44 (Supplement 1): S15–S33. doi:10.2337/dc21-S002. ISSN 0149-5992. PMID 33298413.
  2. Vann, Mary Ann (2014-06). "Management of Diabetes Medications for Patients Undergoing Ambulatory Surgery". Anesthesiology Clinics. 32 (2): 329–339. doi:10.1016/j.anclin.2014.02.008. Check date values in: |date= (help)
  3. Joshi, Girish P.; Chung, Frances; Vann, Mary Ann; Ahmad, Shireen; Gan, Tong J.; Goulson, Daniel T.; Merrill, Douglas G.; Twersky, Rebecca (2010-12). "Society for Ambulatory Anesthesia Consensus Statement on Perioperative Blood Glucose Management in Diabetic Patients Undergoing Ambulatory Surgery:". Anesthesia & Analgesia. 111 (6): 1378–1387. doi:10.1213/ANE.0b013e3181f9c288. ISSN 0003-2999. Check date values in: |date= (help)
  4. Frisch, A.; Chandra, P.; Smiley, D.; Peng, L.; Rizzo, M.; Gatcliffe, C.; Hudson, M.; Mendoza, J.; Johnson, R.; Lin, E.; Umpierrez, G. E. (2010-08-01). "Prevalence and Clinical Outcome of Hyperglycemia in the Perioperative Period in Noncardiac Surgery". Diabetes Care. 33 (8): 1783–1788. doi:10.2337/dc10-0304. ISSN 0149-5992. PMC 2909062. PMID 20435798.CS1 maint: PMC format (link)
  5. Levetan, C. S.; Passaro, M.; Jablonski, K.; Kass, M.; Ratner, R. E. (1998-02-01). "Unrecognized Diabetes Among Hospitalized Patients". Diabetes Care. 21 (2): 246–249. doi:10.2337/diacare.21.2.246. ISSN 0149-5992.
  6. Buchleitner, Ana Maria; Martínez-Alonso, Montserrat; Hernández, Marta; Solà, Ivan; Mauricio, Didac (2012-09-12). Cochrane Metabolic and Endocrine Disorders Group (ed.). "Perioperative glycaemic control for diabetic patients undergoing surgery". Cochrane Database of Systematic Reviews. doi:10.1002/14651858.CD007315.pub2.
  7. Kroin, Jeffrey S.; Buvanendran, Asokumar; Li, Jinyuan; Moric, Mario; Im, Hee-Jeong; Tuman, Kenneth J.; Shafikhani, Sasha H. (2015-06). "Short-Term Glycemic Control Is Effective in Reducing Surgical Site Infection in Diabetic Rats:". Anesthesia & Analgesia. 120 (6): 1289–1296. doi:10.1213/ANE.0000000000000650. ISSN 0003-2999. Check date values in: |date= (help)
  8. 8.0 8.1 Research, Center for Drug Evaluation and (2021-01-11). "FDA revises labels of SGLT2 inhibitors for diabetes to include warnings about too much acid in the blood and serious urinary tract infections". FDA.
  9. 9.0 9.1 Seger, Christian D.; Xing, Hanning; Wang, Libing; Shin, John S. (2021-01-14). "Intraoperative Diagnosis of Sodium-Glucose Cotransporter 2 Inhibitor–Associated Euglycemic Diabetic Ketoacidosis: A Case Report". A&A Practice. 15 (1): e01380. doi:10.1213/XAA.0000000000001380. ISSN 2575-3126.
  10. "National Diabetes Statistics Report, 2020 | CDC". www.cdc.gov. 2020-09-28. Retrieved 2021-07-12.