Perioperative management of blood glucose in adults with diabetes mellitus
- Nadia A Khan, MD, MSc
Nadia A Khan, MD, MSc
- Assistant Professor of Medicine
- University of British Columbia, Canada
- William A Ghali, MD, MPH
William A Ghali, MD, MPH
- Canada Research Chair
- Departments of Medicine and Community Health Sciences
- University of Calgary, Canada
- Enrico Cagliero, MD
Enrico Cagliero, MD
- Associate Professor of Medicine
- Harvard Medical School
- Section Editors
- David M Nathan, MD
David M Nathan, MD
- Editor-in-Chief — Endocrinology
- Section Editor — Diabetes Mellitus
- Professor of Medicine
- Harvard Medical School
- Stephanie B Jones, MD
Stephanie B Jones, MD
- Editor-in-Chief — Anesthesiology
- Section Editor — Anesthesia with Comorbid Non-Cardiopulmonary Conditions
- Associate Professor of Anesthesia
- Harvard Medical School
Diabetes mellitus is a common chronic disorder, affecting approximately 8 percent of the United States population . Patients with diabetes have an increased incidence of cardiovascular disease and this, combined with the frequent microvascular complications of the disease, often translate into more surgical interventions.
Careful assessment of patients with diabetes prior to surgery is required because of their complexity and high risk of coronary heart disease, which may be relatively asymptomatic compared with the nondiabetic population. Diabetes mellitus is also associated with increased risk of perioperative infection and postoperative cardiovascular morbidity and mortality [2,3].
One key aspect of the perioperative management is glycemic control; complex interplay of the operative procedure, anesthesia, and additional postoperative factors such as sepsis, disrupted meal schedules and altered nutritional intake, hyperalimentation, and emesis can lead to labile blood glucose levels. A rational approach to diabetes mellitus management allows the clinician to anticipate alterations in glucose and improve glycemic control perioperatively .
This review will discuss the preoperative evaluation of patients with diabetes, general goals of glycemic control, and management of blood glucose in the perioperative phase. The special circumstances of glucocorticoid therapy and hyperalimentation are also reviewed. More details regarding glucose control in hospitalized patients in general are found separately. (See "Management of diabetes mellitus in hospitalized patients" and "Glycemic control and intensive insulin therapy in critical illness".)
Clinical evaluation — The preoperative evaluation of any patient, including those with diabetes mellitus, focuses on cardiopulmonary risk assessment and modification. Coronary heart disease is much more common in individuals with diabetes than in the general population, and in addition, patients with diabetes have an increased risk of silent ischemia [5,6]. Therefore, assessment of cardiac risk is essential in patients with diabetes . Other associated conditions, such as hypertension, obesity, chronic kidney disease, cerebrovascular disease, and autonomic neuropathy, need to be assessed prior to surgery as these conditions may complicate anesthesia and postoperative care. (See "Prevalence of and risk factors for coronary heart disease in diabetes mellitus" and "Evaluation of cardiac risk prior to noncardiac surgery" and "Anesthesia for the obese patient" and "Overview of complications occurring in the post-anesthesia care unit".)
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- PREOPERATIVE EVALUATION
- Clinical evaluation
- EFFECT OF SURGERY ON GLUCOSE CONTROL
- GOALS OF GLYCEMIC CONTROL
- General goals
- Glycemic targets
- PERIOPERATIVE PHASE
- Type 2 diabetes treated with diet alone
- Type 2 diabetes treated with oral hypoglycemic agents/noninsulin injectables
- Type 1 or insulin treated type 2 diabetes
- - Short procedures
- - Long and complex procedures
- Glucose insulin potassium infusion
- Separate insulin and glucose intravenous solutions
- POSTOPERATIVE PHASE
- CORRECTION INSULIN
- SPECIAL CONSIDERATIONS
- Glucocorticoid therapy
- Emergency procedures
- SUMMARY AND RECOMMENDATIONS