Perioperative management of adult diabetic patients. Intraoperative period

Perioperative Management of the Patient with Diabetes Mellitus

Perioperative evaluation and management of diabetes mellitus is vital to minimize adverse complications before, during, and after surgery. It requires a multidisciplinary approach including the surgery team, anesthesia, endocrinology or internal medicine, and other specialties as needed. This article will discuss the effects of surgery and anesthesia on blood glucose, preoperative evaluation of the person with diabetes, glycemic targets for surgery, adjustment of diabetes medications the day before surgery, in the preoperative, intraoperative, and postoperative areas, management of blood glucose in the preoperative, intraoperative, and postoperative periods, and management of hypoglycemia.

Comparison of the patients with diabetes mellitus using either insulin or oral antidiabetic drug in terms of difficult laryngoscopy: A randomized controlled study

Aim

We aimed to evaluate the differences in the difficult laryngoscopy as a general anesthetic component in patients with Diabetes Mellitus (DM) using either insulin or oral antidiabetic drug (OADD).

Materials and Methods

This study was planned for a total of 230 patients including DM patients and non-DM patients as a control group who would undergo elective surgery between 30.01.2020-30.04.2020. Age, gender, body mass index (BMI), Mallampati scores, thyromental distance (TMD), inter-incisor distance (IID), and neck extension measurements were noted. Preoperative HbA1C levels, DM type, diagnosis time, and duration of insulin or OADD use were recorded. Patients without DM (Group C), patients using insulin (Group I), and patients using OADD (Group D) were separated respectively. Cormack-Lehane (CL) classification of the airway, number of laryngoscopic attempts, intubation success at the first attempt, intubation duration, performance of backward-upward-rightward pressure (BURP) maneuver, and requirement of use of different airway equipment were compared between the groups.

Results

The data of 192 patients were compared. The mean IID (mm) was lower in Groups I and D than C. It was the lowest in Group I. Presence of neck extension of more than 30° in Groups I and D was lower than C. Classification of CL in Groups I and D was higher than C. Number of laryngoscopic attempts was higher in Groups I and D than C. Intubation success at the first attempt was lower in Groups I and D than C. The intubation duration was longer in Groups I and D than C. It was the longest in Group I. The more BURP maneuvering was required in Groups I and D than C. In Groups I and D, the number of uses of different airway equipment was higher than in Group C. The rate of using a videolaryngoscope (VL) in Group I was higher than in Groups D and C.

Conclusion

Difficult laryngoscopy was more common in DM patients. Moreover, in patients with DM using insulin, VL use was more often and intubation duration was longer than in patients with DM using OADD.

Type 1 Diabetes Overview and Perioperative Management

Type 1 diabetes (T1D) is an increasingly common condition. Although often more effective, treatment regimens for patients with T1D have become more variable and complex with newer insulin analogues and increasing use of diabetes technology. Both surgery and anesthesia are known to trigger a stress response that causes dramatic metabolic changes in the patient that tend to increase glucose variability. Close monitoring of glucose levels and clear algorithms for insulin administration can ameliorate these characteristic responses. As T1D treatment technology becomes more effective at maintaining glucose in target range, there should be more consideration of using this technology during hospitalization and surgery.

The Effect of Postinduction Blood Glucose on Intraoperative Hypothermia

Background and Objectives: Hypothermia frequently occurs in patients undergoing surgery and is associated with adverse complications. Therefore, this study aimed to investigate the postinduction blood glucose and occurrence of intraoperative hypothermia in patients undergoing laparoscopic surgery. Materials and Methods: This retrospective observational study included 334 patients aged ≥20 years who had undergone elective laparoscopic surgery. The primary outcome of this study was the incidence of intraoperative hypothermia. Stratified analysis revealed differences between patients with and without diabetes. Results: Hypothermia occurred in 200 (59.9%) patients. In multivariate analysis, out-of-range postinduction glucose was independently associated with hypothermia (>150 mg/dL: odds ratio 2.17, 95% confidence interval (1.02, 4.61), p = 0.045; <110 mg/dL: odds ratio 2.02, 95% confidence interval (1.15, 3.55), p = 0.015), whereas preoperative HbA1c >6% was not significantly associated with hypothermia (odds ratio 1.02, 95% confidence interval (0.56, 1.84), p = 0.961). Considering only patients with diabetes, the incidence of hypothermia was lower (p = 0.002), the duration of hypothermia was shorter (p = 0.007), and the minimum temperature was higher (p = 0.006) in those with a postinduction glucose level of 110-150 mg/dL. Conclusions: The postinduction glucose level is independently associated with intraoperative hypothermia. Out-of-range postinduction glucose appeared to have an impact on the development of hypothermia in patients with diabetes, especially those with a postinduction glucose level <110 mg/dL.

Surgical Pharmacy for Optimizing Medication Therapy Management Services within Enhanced Recovery after Surgery (ERAS®) Programs

Drug-related problems (DRPs) are common among surgical patients, especially older patients with polypharmacy and underlying diseases. DRPs can potentially lead to morbidity, mortality, and increased treatment costs. The enhanced recovery after surgery (ERAS) system has shown great advantages in managing surgical patients. Medication therapy management for surgical patients (established as "surgical pharmacy" by Guangdong Province Pharmaceutical Association (GDPA)) is an important part of the ERAS system. Improper medication therapy management can lead to serious consequences and even death. In order to reduce DRPs further, and promote the rapid recovery of surgical patients, the need for pharmacists in the ERAS program is even more pressing. However, the medication therapy management services of surgical pharmacy and how surgical pharmacists should participate in ERAS programs are still unclear worldwide. Therefore, this article reviews the main perioperative medical management strategies and precautions from several aspects, including antimicrobial agents, antithrombotic agents, pain medication, nutritional therapy, blood glucose monitoring, blood pressure treatment, fluid management, treatment of nausea and vomiting, and management of postoperative delirium. Additionally, the way surgical pharmacists participate in perioperative medication management, and the relevant medication pathways are explored for optimizing medication therapy management services within the ERAS programs. This study will greatly assist surgical pharmacists' work, contributing to surgeons accepting that pharmacists have an important role in the multidisciplinary team, benefitting medical workers in treating, counseling, and advocating for their patients, and further improving the effectiveness, safety and economy of medication therapy for patients and promoting patient recovery.

Preoperative Carbohydrate Drink Intake Increases Glycemic Variability in Patients with Type 2 Diabetes Mellitus in Total Joint Arthroplasty: A Prospective Randomized Trial

BACKGROUND

Preoperative carbohydrate treatment attenuates insulin resistance and improves metabolism to an anabolic state. Despite these benefits, impaired glycemic control and aspiration risk related to gastroparesis represent concerns for patients with diabetes undergoing surgery. This randomized controlled trial investigated the effects of oral carbohydrate therapy on perioperative glucose variability, metabolic responses, and gastric volume in diabetic patients undergoing elective total hip or knee arthroplasty.

METHODS

Fifty diabetic patients scheduled to undergo elective total knee or hip arthroplasty during August 2019-October 2020 were randomly assigned to a control or carbohydrate therapy (CHO) group. CHO group of patients received a 400-mL carbohydrate drink 2-3 h before anesthesia; control group of patients underwent overnight fasting from midnight, one night before surgery. Blood glucose levels were measured before intake of the carbohydrate drink, before spinal anesthesia, preoperatively, immediately postoperatively, and 1 h postoperatively. Insulin level and gastric volume were measured before spinal anesthesia.

RESULTS

The glucose variability of patients in the CHO group was significantly higher than that of those in the control group (16.5 vs. 10.1%, P = 0.008). Similarly, insulin resistance was higher in the CHO group than in the control group (8.5 vs. 2.7, P < 0.001). The gastric volume did not differ significantly between the groups (61.3 vs. 15.2 ml, P = 0.082).

CONCLUSIONS

Preoperative oral carbohydrate therapy increases glucose variability and insulin resistance in diabetic patients. Therefore, carbohydrate beverages should be cautiously administered to diabetic patients, considering metabolic and safety aspects. Trial registration number ClinicalTrials.gov (No. NCT04013594).

Feasibility and postoperative opioid sparing effect of an opioid-free anaesthesia in adult cardiac surgery: a retrospective study

Background

No previous study investigated the dexmedetomidine-based opioid-free anesthesia (OFA) protocol in cardiac surgery. The main objective of this study was to evaluate the feasibility and the postoperative opioid-sparing effect of dexmedetomidine-based OFA in adult cardiac surgery patients.

Methods

We conducted a single-centre and retrospective study including 80 patients above 18 years old who underwent on-pump cardiac surgery between November 2018 and February 2020. Patients were divided into two groups: OFA (lidocaine, ketamine, dexmedetomidine, MgSO4) or opioid-based anaesthesia (remifentanil and anti-hyperalgesic medications such as ketamine and/or MgSO4 and/or lidocaine at the discretion of the anesthesiologist). The primary endpoint was the total amount of opioid consumed in its equivalent of intravenous morphine during the first 48 postoperative hours. Secondary outcomes included perioperative hemodynamics, post-operative maximal pain at rest and during coughing and adverse outcomes. Data are expressed as median [interquartile range].

Results

Patients in the OFA-group had a higher EuroSCORE II, with more diabetes, more dyslipidemia and more non-elective surgery but fewer smoking history. In the OFA group, the median loading dose of dexmedetomidine was 0.6 [0.4–0.6] μg.kg^− 1 while the median maintenance dose was 0.11 μg.kg^− 1.h^− 1 [0.05–0.20]. In 10 (25%) patients, dexmedetomidine was discontinued for a drop of mean arterial pressure below 55 mmHg. The median total amount of opioid consumed in its equivalent of intravenous morphine during the first 48 postoperative hours was lower in the OFA group (15.0 mg [8.5–23.5] versus 30.0 mg [17.3–44.3], p < 0.001). While no differences were seen with rest pain (2.0 [0.0–3.0] versus 0.5 [0.0–5.0], p = 0.60), the maximal pain score during coughing was lower in OFA group (3.5 [2.0–5.0] versus 5.5 [3.0–7.0], p = 0.04). In OFA group the incidence of atrial fibrillation (18% versus 40%, p = 0.03) and non-invasive ventilation use (25% versus 48%, p = 0.04) were lower. The incidence of bradycardia and the intraoperative use of norepinephrine were similar between both groups.

Conclusion

Dexmedetomidine-based OFA in cardiac surgery patients is feasible and could be associated with a lower postoperative morphine consumption and better postoperative outcomes. Further randomized studies are required to confirm these promising results and determine the optimal associations, dosages, and infusion protocols during cardiac surgery.

Graphical abstract

Supplementary Information

The online version contains supplementary material available at 10.1186/s12871-021-01362-1.

[Treatment of diabetes mellitus in perioperative medicine-an update]

Patients with diabetes who undergo a surgical intervention have an increased risk of metabolic derailment, anesthesiological complications, postoperative infections and cardiovascular events. The treatment of diabetes mellitus is subject to a continuous further development due to pharmaceutical and technical innovations. This article presents the implications of the current concepts of diabetes treatment for perioperative medicine, particularly the changes due to new oral antidiabetic agents and insulin pump treatment. Some of the currently available guidelines are discussed with respect to the care of diabetes patients in childhood and adulthood in connection with an operation. Finally, possible perspectives in the field of monitoring and treatment of diabetes patients are discussed.

The effect of dexmedetomidine on intraoperative blood glucose homeostasis: secondary analysis of a randomized controlled trial

Purpose

To investigate the effect of dexmedetomidine on intraoperative blood glucose hemostasis in elderly patients undergoing non-cardiac major surgery.

Methods

This was secondary analysis of a randomized controlled trial. Patients in dexmedetomidine group received a loading dose dexmedetomidine (0.6 μg/kg in 10 min before anaesthesia induction) followed by a continuous infusion (0.5 μg/kg/hr) till 1 h before the end of surgery. Patients in control group received volume-matched normal saline at the same time interval. Primary outcome was the incidence of intraoperative hyperglycemia (blood glucose higher than 10 mmol/L).

Results

303 patients in dexmedetomidine group and 306 patients in control group were analysed. The incidence of intraoperative hyperglycemia showed no statistical significance between dexmedetomidine group and control group (27.4% vs. 22.5%, RR = 1.22, 95%CI 0.92–1.60, P = 0.167). Median value of glycemic variation in dexmedetomidine group (2.5, IQR 1.4–3.7, mmol) was slightly lower than that in control group (2.6, IQR 1.5–4.0, mmol), P = 0.034. In multivariable logistic analysis, history of diabetes (OR 3.007, 95%CI 1.826–4.950, P < 0.001), higher baseline blood glucose (OR 1.353, 95%CI 1.174–1.560, P < 0.001) and prolonged surgery time (OR 1.197, 95%CI 1.083–1.324, P < 0.001) were independent risk factors of hyperglycaemia.

Conclusions

Dexmedetomidine presented no effect on intraoperative hyperglycemia in elderly patients undergoing major non-cardiac surgery.

Trial registration

Present study was registered at Chinese Clinical Trial Registry on December 1, 2015 (www.chictr.org.cn, registration number ChiCTR-IPR-15007654).

Preoperative Carbohydrate Drinks Do Not Decrease Postoperative Nausea and Vomiting in Type 2 Diabetic Patients Undergoing Total Knee Arthroplasty-A Randomized Controlled Trial

INTRODUCTION

We evaluated whether preoperative carbohydrate drink would be able to decrease postoperative nausea and vomiting (PONV) and improve the quality of recovery (QoR) in diabetic patients undergoing total knee arthroplasty (TKA).

METHODS

Eighty-two patients were randomized to either the intravenous (IV) Dextrose group (n = 41) or Oral carbohydrate (CHO) group (n = 41). The IV Dextrose group received dextrose solution mixed with insulin while fasting, and the Oral CHO group received carbohydrate drinks preoperatively. PONV was assessed up to postoperative 36 hours, and QoR was assessed before surgery and on postoperative day (POD) 1. Blood glucose was measured from the morning of surgery until POD 1.

RESULTS

PONV scores were not different between the groups. Postoperative QoR scores were significantly higher in the Oral CHO group (median [interquartile range]; 160 [153 to 167]) than the IV Dextrose group (155 [147 to 159]) (P = 0.009), but the difference did not meet the minimal clinically important difference. Blood glucose was comparable between the groups.

DISCUSSION

Preoperative CHO drink did not reduce PONV in diabetic patients after total knee arthroplasty. A statistically significant but clinically questionable improvement in the QoR was seen in the Oral CHO group. However, preoperative CHO drink did not increase hyperglycemia, which suggests that it may be a safe component of perioperative care in diabetic patients.

Comparison of Dexamethasone 4mg vs 8mg Doses in Total Joint Arthroplasty Patients: A Retrospective Analysis

Introduction

Dexamethasone is commonly administered intraoperatively to control postoperative nausea and vomiting (PONV) and pain. There is limited evidence of the ideal dosage of dexamethasone during surgery. Dexamethasone administration may increase blood glucose levels, posing unique challenges in maintaining acceptable blood glucose levels in patients with diabetes.

Objective

Compare two doses of dexamethasone (4mg and 8mg) for outcomes in patients undergoing hip and knee arthroplasty.

Methods

Medical records of 3,194 patients having undergone total hip arthroplasty (THA) and total knee arthroplasty (TKA) between January 1, 2016 and December 31, 2017 who were administered dexamethasone were reviewed. The eligible population included male and female patients aged 18-89, who underwent elective hip and knee replacement surgery and were administered dexamethasone intraoperatively. Demographics, clinical variables, and preoperative diabetic status were recorded. Primary outcomes included: blood glucose levels, incidence of PONV, post-anesthesia care unit (PACU) time, and length of stay (LOS). Postoperative complications such as periprosthetic joint injection and urinary tract infections (UTI) were also examined within 90 days of surgery. The 30-day readmissions rate was also collected for analysis.

Results

There was no PONV in the entire patient population. There were no significant differences between 4mg and 8mg dexamethasone in patients with or without diabetes, for preop to postop blood glucose difference, surgical timing, and post-operative complications.

Conclusion

Dexamethasone in both 4mg and 8mg dose was effective in PONV prophylaxis. The effects of 4mg and 8mg dexamethasone were the same in individuals with and without diabetes and the increases in blood glucose were not significantly different. Dexamethasone should not be withheld, as its benefits seem to outweigh the risks even in patients with diabetes.

Insight Into the Perioperative Management of Type 2 Diabetes

Diabetic people are at risk of developing acute complications when exposed to stress. Surgery brings a stressful period when the patient is exposed not only to surgical stress but also the effects of medications used during that particular period. The patient's comorbidities can influence the perioperative management of diabetes. Poorly controlled diabetes can complicate the hospital course. The literature was searched through PubMed and the articles of the last 5 years, from 2014 to 2019, were looked into. The studies available as a free text, in the English language and related to humans, were included. Inclusion criteria also included adults with type 2 diabetes undergoing surgery. The perioperative management of diabetes is a challenging one. Apart from the diabetes control; comorbidities, general health, intake, and interaction of medications both anti-diabetic and non-diabetic, type and duration of surgery, are some of the factors that influence the outcome of the surgery. With a variety of options available to manage diabetes currently, it is important to have a good insight into their effects to prevent complications to occur and ensure safe discharge from the hospital. The good control of diabetes is essential in bringing favorable outcomes. The perioperative management of diabetes should be individualized. Oral anti-hyperglycemic medications, other than sulfonylureas and SGLT2 inhibitors, provide a reasonable alternative to insulin and can be continued safely perioperatively depending upon the type of surgery and the patient is expected to resume oral intake soon postoperatively.

Use of continuous subcutaneous insulin infusion (CSII) therapy in pediatric diabetes patients in the perioperative period

Diabetes mellitus is one of the most common endocrinopathies encountered in the perioperative period, and the pediatric population is increasingly using continuous subcutaneous insulin infusions for diabetes management. As these patients present for procedures or surgery requiring anesthesia, the anesthesia provider is charged with the task of managing these pumps perioperatively. Here, we review our experience from a large tertiary care academic medical center and propose recommendations for the perioperative management of children and adolescents with diabetes who use insulin pumps.

Perioperative Management of Diabetes Mellitus: Novel Approaches

PURPOSE OF REVIEW

Several studies have demonstrated the benefits of glycemic control in the perioperative period and there is ongoing interest in development of systematic approaches to achieving glycemic control. This review discusses currently available data and proposes a new approach to the management of hyperglycemia in the perioperative period.

RECENT FINDINGS

In a recent study, we demonstrated that early preoperative identification of patients with poorly controlled diabetes and proactive treatment through various phases of surgery improves glycemic control, lowers the risk of surgical complications, and decreases the length of hospital stay. Implementation of a perioperative diabetes program that systematically identifies and treats patients with poor glycemic control early in the preoperative period is feasible and improves clinical care of patients undergoing elective surgery.