Perioperative Management of Diabetes Mellitus Author: Nadia A. Khan, MD; William A. Ghali, MD; Susan E. Spratt, MD; Melanie E. Mabrey, MSN, ACNP, BC-ADM
Editorial changes - 2009-09-16
Author information and module status
Elements of Risk
Whom and How to Assess
Interventions to Decrease Risk
Patient Education
Follow-up
Tables
Figures
References
Glossary
What's New
Patient Information
Additional Resources
Tools
Whom and How to Assess
  • Identify patients who may be at risk for developing DKA as part of the routine preoperative evaluation.
  • Assess for patient-related risk of hypoglycemia.
  • Assess overall health status of patients with diabetes when determining the patient-related risk of perioperative cardiac complications.
  • Determine the type of surgical procedure and planned anesthesia technique.
  • Assess preoperative glucose levels in all patients with diabetes to stratify their risk for postoperative wound infections.
  • Determine renal function in all patients with diabetes.
  • Perform preoperative urinalysis in only selected situations for diabetic patients.
  • Use abnormalities found on resting ECGs to further stratify cardiac risk.

Identify patients who may be at risk for developing DKA as part of the routine preoperative evaluation. C

  • Identify patients with type 1 diabetes and insulin-deficient type 2 diabetes.
  • Recognize that all patients with type 1 diabetes are at risk for developing postoperative ketoacidosis.
  • In patients with type 1 diabetes, look for ketoacidosis by testing serum ketones, bicarbonate level, and anion gap, and if these tests are abnormal postpone surgery and treat with insulin and fluids.
  • Consider patients with type 2 diabetes and any of the following characteristics to be prone to ketoacidosis:
    • Young age (under age 40)
    • Use of insulin alone to control hyperglycemia
    • BMI <25 kg/m2
    • History of DKA
    • Family history of type 1 diabetes
    • History of pancreatectomy or pancreatic dysfunction
  • Recognize that hyperglycemia can be precipitated by stress or infection.
  • Recognize that iatrogenic hyperglycemia can be caused by the administration of pharmacologic agents such as vasopressors or glucocortiocids or by withholding pharmacologic agents such as insulin.
  • Recognize that pancreatic surgery can increase the risk of derangement of glycemic control in all patients, regardless of whether they have been diagnosed with diabetes.
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Assess for patient-related risk of hypoglycemia. C

  • Ask about:
    • Previous episodes of glucose readings <70 mg/dL (4.0 mmol/L)
    • Symptoms of lightheadedness, diaphoresis, and nausea that are ameliorated with eating
  • Determine the frequency, severity, and awareness of the hypoglycemic episodes, including:
    • Loss of consciousness, which denotes severe hypoglycemia
    • Patient awareness of minor symptoms, such as agitation, fatigue, lightheadedness, feeling cold
  • Determine the factors that may explain the episodes of hypoglycemia, such as:
    • Low intake of calories at specific times
    • Excessive exercise
    • Excessive use of insulin or sulfonylureas corresponding to times of hypoglycemia
  • Determine if the patient's home dose of insulin is accurate:
    • Ascertain how the patient takes insulin at home; inquire if the glucose level is normal or low if insulin is not given
    • Ascertain whether the patient experiences hypoglycemia if a meal is skipped
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Assess overall health status of patients with diabetes when determining the patient-related risk of perioperative cardiac complications. B

  • Check HbA1C in all patients undergoing cardiac surgery, even if they have not been diagnosed with diabetes.
  • Determine the level of risk for having a perioperative cardiac complication using the Revised Cardiac Index and the ACC/AHA guidelines for perioperative cardiovascular evaluation for noncardiac surgery.
  • Consider whether the patient requires further noninvasive cardiac testing as part of the preoperative evaluation.
  • See module Preoperative Cardiac Risk Assessment.
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Determine the type of surgical procedure and planned anesthesia technique. B

  • Assess whether the patient will undergo minor or major surgery to determine the desired target glucose range and the strategy to control hyperglycemia:
    • A minor surgical procedure is of short duration with minimal fluid shifts or tissue dissection
    • Major surgery is a procedure that is long and complex, such as:
      • Intra-abdominal or intrathoracic procedures
      • Cardiac surgery
      • Major vascular surgery
      • Multiple trauma surgery
      • Prolonged neurosurgery (>4 hours)
      • Transplantation surgery
  • Determine if the patient will be undergoing epidural anesthesia or general anesthesia.
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Assess preoperative glucose levels in all patients with diabetes to stratify their risk for postoperative wound infections. BC

  • Obtain serum glucose levels (pre-meal or fasting) at the time of the preoperative assessment for the purposes of risk stratification for postoperative wound infections and to determine if additional medical therapy may be needed upon discharge.
  • Consider postponing elective surgery if glucose levels are very high (>220 mg/dL or >12 mmol/L) or if patients have signs or symptoms of dehydration due to hyperglycemia until glucose levels are normalized and symptoms have resolved.
  • See figure HbA1C Guidance.
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Determine renal function in all patients with diabetes. B

  • Obtain preoperative serum creatinine level and possibly BUN levels for all patients with diabetes.
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Perform preoperative urinalysis in only selected situations for diabetic patients. B

  • Do not obtain a urinalysis to screen for urinary tract infection in asymptomatic patients with diabetes as part of a routine preoperative screening for most surgical procedures.
  • Perform routine preoperative urinalysis screening in all patients undergoing urologic and perhaps orthopedic procedures.
  • Obtain a urinalysis in patients with symptoms of urinary tract infection.
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Use abnormalities found on resting ECGs to further stratify cardiac risk. B

  • Screen all patients with diabetes with a resting 12-lead ECG, specifically looking for:
    • Abnormal Q waves suggesting old MI
    • Cardiac rhythm other than sinus
    • Ventricular or atrial ectopy
  • See module Preoperative Cardiac Risk Assessment
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FAQs
Melanie E. Mabrey, MSN, ACNP, BC-ADM has no financial relationships with pharmaceutical companies, biomedical device manufacturers, or health-care related organizations. Nadia A. Khan, MD has no financial relationships with pharmaceutical companies, biomedical device manufacturers, or health-care related organizations. Susan E. Spratt, MD, Consultant and speaker for Sanofi Aventis and Novo Nordisk. William A. Ghali, MD has no financial relationships with pharmaceutical companies, biomedical device manufacturers, or health-care related organizations.
Darren B. Taichman, MD, PhD, Editor, PIER, has received grant support from Actelion Pharmaceuticals Ltd , and honoraria for continuing medical education grand rounds and lectures given.

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