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.

Preoperative considerations for patients with diabetes

INTRODUCTION

Patients undergoing surgery require a thorough assessment preoperatively. Hyperglycemia is associated with poor outcomes, and stability of glucose levels is an important factor in preoperative management. Diabetes presents a particular challenge since patients are often on multiple medications encompassing glycemic management and cardiovascular therapies.

AREAS COVERED

A PubMed search of published data and reviews on preoperative approaches in diabetes was conducted. Consensus opinion drives most of the guidelines and recommendations for management of diabetes in surgical patients. Pathophysiology is often complex with varying levels of glucose and surgical stress. Establishing well-controlled diabetes prior to surgical intervention should be standard practice in non-emergent procedures. We review the best practices for implementing preoperative assessment, with diabetes with a focus on diabetes medications.

EXPERT OPINION

The management of a patient preoperatively varies by region and country. Institutions differ in approaches to preoperative evaluation and the establishment of consistent approaches would provide a platform for monitoring patient outcomes. Multidisciplinary teams and pre-assessment clinics for preoperative evaluation can enhance patient care for those undergoing surgery.

Peri-operative management of diabetes mellitus - A survey of current practices among Indian anesthesiologists

Background and Aims

Increased burden of diabetes in India has resulted in a spurt in the number of patients with diabetes posted for surgeries. The paucity of national guidelines can lead to marked practice variations in the peri-operative management of diabetes. This survey intends to discern current peri-operative practices among anesthesiologists working in medical colleges, tertiary care government, and private health care institutes of the country.

Material and Methods

An anonymous online survey comprising of 25 closed-ended questions was conducted using Google Forms® and disseminated through social media, emails, and messaging platforms. The questionnaire dealt primarily with the peri-operative management of diabetes in patients scheduled for elective surgery. The survey was conducted over a period of 1 month and targeted anesthesia resident trainees with more than 1-year experience, senior residents, and consultants working in India.

Results

Statistically significant difference was observed between the three types of health facilities with respect to prior evaluation for diabetes (P = 0.007), prioritizing operative list (P = 0.006), hospital encouragement of day care surgery (P < 0.001), glycated hemoglobin level (HbA1c) level >8.5 for postponement of surgery (P < 0.05), insulin infusion preference (P < 0.001), hourly intra-operatively capillary blood glucose (CBG) assessment (P = 0.021), and avoiding peri-operative use of Ringer's lactate (RL) (P = 0.025).

Conclusion

This survey primarily highlights the lack of prioritizing the operative list, early discontinuation of metformin, and reduced tendency to consider diabetics for day care surgeries.

Current practice in the perioperative management of patients with diabetes mellitus: a narrative review

The prevalence of diabetes is increasing, and patients with diabetes mellitus have both an increased likelihood of requiring surgery and of developing postoperative complications when they do. We summarise available evidence underpinning current guidelines on preoperative assessment and optimisation, perioperative management of prescribed insulin and oral hypoglycaemic medication, intraoperative glycaemic control, and postoperative patient care.

Sodium-glucose cotransporter 2 inhibitor-associated perioperative ketoacidosis: a systematic review of case reports

Although the recommended preoperative cessation period for sodium-glucose cotransporter 2 inhibitors (SGLT2is) changed in 2020 (from 24 h to 3-4 days preoperatively) to reduce the risk of SGLT2i-associated perioperative ketoacidosis (SAPKA), the validity of the new recommendation has not been verified. Using case reports, we assessed the new recommendation effectiveness and extrapolated precipitating factors for SAPKA. We searched electronic databases up to June 1, 2022 to assess SAPKA (blood pH < 7.3 and blood or urine ketone positivity within 30 days postoperatively in patients taking SGLT2i). We included 76 publications with 99 cases. The preoperative SGLT2i cessation duration was reported for 59 patients (59.6%). In all cases with available cessation periods, the SGLT2is were interrupted < 3 days preoperatively. No SAPKA cases with > 2-day preoperative cessation periods were found. Many case reports lack important information for estimating precipitating factors, including preoperative SGLT2i cessation period, body mass index, baseline hemoglobin A1c level, details of perioperative fluid management, and type of anesthesia. Our study suggested that preoperative SGLT2i cessation for at least 3 days could prevent SAPKA. Large prospective epidemiologic studies are needed to identify risk factors for SAPKA.

Glucose management team significantly improves glycaemic care and commitment to in-hospital guidelines within arthroplastic patients

BACKGROUND

Perioperative dysglycaemias are a risk for harm but guidelines to improve glucose management are poorly adhered to.

AIM

To determine whether a specialized team and diabetes education improves the implementation of guidelines and glucose values.

METHODS

We conducted a prospective study of 611 nonselected, consecutive patients attending for elective hip or knee arthroplasty. The first 209 patients received conventional care and the following 402 patients received intervention (Acute Glucose Service, AGS) in two chronological groups; either perioperatively (AGS1) or also preoperatively (AGS2). The AGS-team provided diabetes education, identified the patients with diabetes risk and adjusted the medication when needed. Capillary plasma glucose (CPG) was repeatedly measured and glycated haemoglobin (HbA1c) obtained before and after the surgery. The study objectives were to evaluate the staff actions when hyperglycaemia was severe (CPG >10 mmol/L), and to assess improvement of the glycaemic values and the complication rate within 3 months.

RESULTS

None of the severely hyperglycaemic events in the reference group were treated according to guidelines. In the AGS 1 group, 50% and in the AGS2 group, 53% were appropriately managed (p < .001). The events of hyperglycaemia (CPG >7.8 mmol/L at least twice) and of severe hyperglycaemia (CPG >10 mmol/L) decreased in all patient groups. The medians of the highest, mean and variability of CPG values improved. The mean HbA1c improved significantly within AGS 2. There was no association between improved glycaemic care and early complications.

CONCLUSIONS

AGS intervention significantly improves adherence to guidelines and glucose values.

Variability of Clinical Practice Management of Type 1 and Type 2 Diabetes During Surgery Across Canada

OBJECTIVE

As part of a larger project to develop quality standards in perioperative diabetes management, the goal of this project was to assess self-reported management of surgical patients with diabetes across healthcare institutions and specialties in Canada.

METHODS

Current practice of perioperative management of patients with diabetes was assessed using multiple-choice questions based on commonly encountered clinical scenarios involving patients with type 1 and type 2 diabetes. The survey was sent to a broad stakeholder group of individuals involved in perioperative medicine in academic and community settings across Canada.

RESULTS

Responses to clinical case scenarios demonstrated more consistent approaches for patients with type 1 diabetes undergoing cardiac surgery, possibly reflecting more robust evidence. There was more variability in the management of noninsulin antihyperglycemic agents and hyperglycemia in patients with type 2 diabetes undergoing noncardiac surgery.

CONCLUSIONS

Given the variability in clinical practice, standards and clinical tools are required for perioperative and periprocedural glycemic management in Canada to inform practice, improve the experience and outcomes for people with diabetes and provide a foundation for quality improvement initiatives and benchmarking.

Perioperative hyperglycaemia in elective arthroplasties. Should we do better?

BACKGROUND

Perioperative dysglycaemia is associated with deleterious outcomes but guidelines to improve glucose management are poorly or inconsistently adhered to. We evaluated glucose management among diabetic and non-diabetic patients undergoing elective hip or knee arthroplasty.

METHODS

Capillary plasma glucose (CPG) was measured prospectively four times daily of 209 patients undergoing elective hip or knee surgery. Actions of the attending teams to CPG values and detection of patients at risk were analysed.

RESULTS

A total of 209 patients were enrolled. All diabetic patients on insulin (6/6) had hyperglycaemia (≥7.8 mmol/l) more than twice and severe hyperglycaemia (>10 mmol/l) at least once. Of the 27 diabetic patients not on insulin 26 (96.3%) had CPG ≥ 7.8 mmol/l ≥ 2 times and 17 (63%) >10 mmol/l. The corresponding figures of the 176 non-diabetic patients were 137 (77.8%) and 61 (34.7%). Severe hyperglycaemia occurred in 54/176 (30.1%) of the non-diabetic patients with pre-operative HbA1c < 42 mmol/mol and random plasma glucose < 7.8 mmol/l. Of the 84 hyperglycaemic episodes > 10 mmol/l, none was treated. Patients with a FINDRISC score ≥ 12 (corresponding to moderate to high risk of diabetes) and hyperglycaemia went unnoticed.

CONCLUSIONS

Hyperglycaemia is common among elective orthopaedic surgery patients with or without diabetes. More than 80% of the 209 patients had hyperglycaemia and 40% had severe hyperglycaemia. None of the patients was treated according to guidelines and none of the patients at risk of hyperglycaemia or diabetes was noticed. There is an obvious need for further education and support by diabetes specialists.

CLINICAL TRIAL REGISTRATION

Clinical trials, gov. NCT03306810.

Long-term preoperative glycemic control restored the perioperative neutrophilic phagocytosis activity in diabetic mice

BACKGROUND

The risk of surgical site infection has been reported to be higher in patients with poorly controlled diabetes. Since chronic hyperglycemia impairs neutrophil functions, preoperative glycemic control may restore neutrophil function. However, long-term insulin therapy may lead to a delay in surgery, which may be a problem, especially in cancer surgery. It is therefore unfortunate that there have been few studies in which the optimal duration of perioperative glycemic control for diabetes with chronic hyperglycemia was investigated. Therefore, we investigated the effects of preoperative long-term insulin therapy and short-term insulin therapy on perioperative neutrophil functions in diabetic mice with chronic hyperglycemia.

METHODS

Five-week-old male C57BL/6 J mice were divided into four groups (No insulin (Diabetes Mellitus: DM), Short-term insulin (DM), Long-term insulin (DM), and Non-diabetic groups). Diabetes was established by administrating repeated low-dose streptozotocin. The Short-term insulin (DM) group received insulin therapy for 6 h before the operation and the Long-term insulin (DM) group received insulin therapy for 5 days before the operation. The No insulin (DM) group and the Non-diabetic group did not receive insulin therapy. At 14 weeks of age, abdominal surgery with intestinal manipulation was performed in all four groups. We carried out a phagocytosis assay with fluorescent microspheres and a reactive oxygen species (ROS) production assay with DCFH-DA (2',7'-dichlorodihydrofluorescein diacetate) before and 24 h after the operation using FACSVerse™ with BD FACSuite™ software.

RESULTS

Blood glucose was lowered by insulin therapy in the Short-term insulin (DM) and Long-term insulin (DM) groups before the operation. Neutrophilic phagocytosis activities before and after the operation were significantly restored in the Long-term insulin (DM) group compared with those in the No insulin (DM) group (before: p = 0.0008, after: p = 0.0005). However, they were not significantly restored in the Short-term insulin (DM) group. Neutrophilic ROS production activities before and after the operation were not restored in either the Short-term insulin (DM) group or Long-term insulin (DM) group.

CONCLUSIONS

Preoperative and postoperative phagocytosis activities are restored by insulin therapy for 5 days before the operation but not by insulin therapy for 6 h before the operation.

Perioperative anesthetic management of patients with diabetes mellitus: focused on blood glucose control

Diabetes mellitus is the most common metabolic disease characterized by elevated blood glucose, which results in damage to the heart, blood vessels, eyes, kidney, and nervous system. The incidence of diabetes mellitus has increased in Korea due to longer life expectancy or lifestyle improvement. Since diabetes affects multiple organs including the cardiovascular, neuroendocrine, and autonomic nervous systems, the risk of postoperative complications such as wound infection and cardiovascular events might be increased in patients with diabetes. In addition to postoperative complications, hypoglycemia or hyperglycemia in diabetes may also cause serious problems during surgery. Preoperative fasting and surgical stress may contribute to the derangement of the patient’s physiological status. For appropriate management of diabetic patients in the perioperative period, patients should be evaluated in detail preoperatively and their blood glucose levels should be checked repeatedly during the surgery and even after surgery. The present paper reviews preoperative, intraoperative, and postoperative management of patients with diabetes.

PROACTIVE PROTOCOL-BASED MANAGEMENT OF HYPERGLYCEMIA AND DIABETES IN COLORECTAL SURGERY PATIENTS

OBJECTIVE

The management of diabetic patients undergoing elective abdominal surgery continues to be unsystematic, despite evidence that standardized perioperative glycemic control is associated with fewer postoperative surgical complications. We examined the efficacy of a pre-operative diabetes optimization protocol implemented at a single institution in improving perioperative glycemic control with a target blood glucose of 80 to 180 mg/dL.

METHODS

Patients with established and newly diagnosed diabetes who underwent elective colorectal surgery were included. The control group comprised 103 patients from January 1, 2011, through December 31, 2013, before protocol implementation. The glycemic-optimized group included 96 patients following protocol implementation from January 1, 2014, through July 31, 2016. Data included demographic information, blood glucose levels, insulin doses, hypoglycemic events, and clinical outcomes (length of stay, re-admissions, complications, and mortality).

RESULTS

Patients enrolled in the glycemic optimization protocol had significantly lower glucose levels intra-operatively (145.0 mg/dL vs. 158.1 mg/dL; P = .03) and postoperatively (135.6 mg/dL vs. 145.2 mg/dL; P = .005). A higher proportion of patients enrolled in the protocol received insulin than patients in the control group (0.63 vs. 0.48; P = .01), but the insulin was administered less frequently (median [interquartile range] number of times, 6.0 [2.0 to 11.0] vs. 7.0 [5.0 to 11.0]; P = .04). Two episodes of symptomatic hypoglycemia occurred in the control group. There was no difference in clinical outcomes.

CONCLUSION

Improved peri-operative glycemic control was observed following implementation of a standardized institutional protocol for managing diabetic patients undergoing elective colorectal surgery.

ABBREVIATIONS

HbA1c = glycated hemoglobin A1c; IQR = interquartile range.