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Diabetes Mellitus (DM)

ASSESSMENT

Data Gathering

History

Symptoms

  • Glucose testing & insulin dosing regimen

  • Recent glucose readings

  • History of hypoglycemic episodes - especially when NPO for procedures

  • History of ketoacidosis

  • Insulin dosing regimen

  • Complications: neuropathy, nephropathy, & gastroparesis

  • Hypoglycemic symptoms & awareness

  • Early satiety & regurgitation of undigested food

Exam

  • Sensory abnormalities

Risk Stratification

Diagnostic Studies

  • Basic metabolic panel within 6 months (more recently if any change in status)

  • ECG if undergoing non-low risk surgery (author's institution's criterion)

  • Glycohemoglobin (A1c) if would impact management

    • Literature mixed on utility & no clear, evidence-based cut-off for elective surgery

    • Many orthopedic surgery programs utilize cut-offs (ranging from 7.0-8.5) above which they will not perform elective surgery; some professional societies also recommend this (Dhatariya et al & Barker et al)

    • Most recent guideline from Endocrine Society recommends targeting a preopative A1c <8%, and if this isn't feasible, at least targeting preoperative glucose of 100-180 mg/dl (Endocrine Society guideline)

  • Fructosamine - alternative to glycohemoglobin:

    • Useful for determining average glucose over past 2-3 weeks; also useful for assessing glucose control in patients with ESRD and chronic hemolytic anemia (A1c unreliable)​

    • Some literature suggests it may be more predictive than A1c of adverse outcomes in orthopedic surgery (Shohat et al & Mendez et al) - fructosamine >293 associated with increased risk of surgical infection

Fructosamine.jpg

MANAGEMENT 

Indications for Surgical Delay

  • Ketoacidosis or hyperosmolar hyperglycemic nonketotic syndrome

  • Elective surgery and A1c exceeding program/institutional cut-off

  • Elective surgery and glucose >400 mg/dl (author's opinion: based upon increased likelihood for immediate complications of hyperglycemia as well as impaired wound healing)

Preoperative Management 

Medication Management (ADA Standards of Medical Care & 2022 Endocrine Society guideline)

  • POSTOPERATIVE GLUCOSE TARGET: 80-180 mg/dl

  • Non-insulin therapies: hold on morning of surgery

    • PREOPERATIVE:

      • Exception: sodium-glucose transport protein 2 (SGLT-2) inhibitors may require withholding fo​r 3 days due to risk of euglycemic ketoacidosis

      • Exception: glucagon-like peptide-1 (GLP-1) agonists may require withholding for week before GI surgery if dosed weekly

    • POSTOPERATIVE:

      • Hold while hospitalized & provide insulin as needed to achieve glucose of 80-180 mg/dl​

      • Use of basal (long-acting) + bolus correction & nutritional (short-acting) insulin preferred over sliding scale-only insulin

  • Insulin​

    • Long-acting (eg, detemir, glargine): provide 60-80% of usual dose while NPO; otherwise continue at usual dose​

      • Exception: For Toujeo and Tresiba, above dose adjustment may need to be done ​3 days before surgery due to extended half-life

    • Intermediate-acting (eg, NPH): provide 1/2 of usual dose while NPO; otherwise continue at usual dose

    • Short-acting (eg, regular, aspart): do not provide nutritional (scheduled for mealtimes) dosing while NPO; provide correction dosing as needed for hyperglycemia while NPO; continue at usual dose when eating usual diet

    • 70/30 or 75/25 insulin: give 1/3 of usual dose or give 50% of the intermediate-acting fraction of the usual dose while NPO; when eating, continue usual dose

    • Insulin pump: 

      • Use 60-80% of usual basal rate & no boluses while NPO

      • If surgery >3 hours or concern for impaired peripheral absorption or patient's ability to self-manage in immediate postoperative setting, remove pump in preop holding area and provide continuous IV insulin infusion (requires preop discussion with patient's diabetes management provider

Intraoperative Management

  • Check glucose prior to surgery & if >300, consider continuous IV insulin infusion

  • Check glucose at least every 2 hours (more frequently if glucose <91 or >180)

  • Give dextrose-containing IV fluids if glucose <91

COUNSELING & COMMUNICATION

  • Collaborate with patients' diabetes management providers, especially if they use insulin pumps

  • Provide preoperative hypoglycemia treatment instructions for while the patient is NPO at home​

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