New recommendations for diabetic perioperative management

According to the National Diabetes Inpatient Audit (NaDIA), people with diabetes occupy around 18% of hospital beds. Diabetes patients are more prone than non-diabetic patients to need surgical intervention, as well as to have perioperative problems (such as infection, poor wound healing or cardiovascular events).

The Centre for Perioperative Care has released new advice on the perioperative care of diabetic patients (CPOC).

While this information is particularly useful for surgeons, anesthesiologists, and diabetic physicians, it may also be useful for younger doctors on call who have questions about such patients.

According to the guidelines, this will necessitate: electronic administration systems that allow for rapid identification of diabetic patients; a named clinical lead for oversight and implementation of perioperative diabetes care specific teams to coordinate individualised perioperative diabetes care for diabetics; and a named clinical lead for oversight and implementation of perioperative diabetes care specific teams to coordinate individualised perioperative diabetes care for diabetics.

To promote pre-operative optimisation, clear communication and referral linkages between primary care, surgical, anaesthesia, and diabetes teams are underlined as essential.

An individualised strategy for surgery and admission

Prior to surgery, CPOC suggests that a care plan be prepared in collaboration with the patient and clinical teams engaged in their care. During the perioperative phase, this care plan should be readily available and referenced to. The following considerations and concerns should be addressed:

HbA1c as a diabetes management indicator kind of diabetes glucose-lowering medicines

the procedure's urgency

degree of metabolic disturbance at the time of presentation (if emergency)

total fasting period projected (one missed meal versus greater than one).

Day surgery versus inpatient admission

Day surgery for particular operations should be considered in diabetics using the same guidelines as non-diabetics. People with diabetes are frequently better at controlling their own diabetes, and admitting them to the hospital might disturb their routine and glycemic control. For diabetic individuals, surgery should be scheduled to minimise the amount of time they are fasting.

Glucose levels should be maintained between 6–12 mmol/L intra-operatively, and CBG should be checked at induction and at least hourly if on insulin or insulin secretagogues, otherwise a minimum of 2 hourly immediate access to glucose metre, ketone metre, and hypoglycemia management should be provided.

Medication adjustment

The guideline offers suggestions for adjusting diabetes medicines the day before and the day of surgery, depending on whether the procedure is scheduled in the morning or afternoon. This reference is for informational purposes only; the UK Clinical Pharmacy Association's The Handbook of Perioperative Medicines has the most up-to-date information.

Long-acting or premixed insulin may normally be maintained the day before and the day of surgery, although at a lower dosage (usually between 50% and 80% depending on the kind of insulin used). This should cut down on the requirement for variable-rate insulin infusions (VRII).

Sodium-glucose transport-2 inhibitors (SLGT-2i) or 'gliflozins,' a novel type of medication currently commonly used in diabetes control, block the SGLT-2 transporter, inhibiting renal glucose reabsorption and thereby reducing blood glucose. They protect the heart and kidneys in a big way. A uncommon but potentially dangerous and life-threatening link has been discovered between SGLT-2i and euglycemic DKA, the risk of which is enhanced when food or fluid intake is restricted (such as fasting for surgical procedures). SLGT-2i should thus be avoided in any patient who has had significant surgery or is suffering from a severe disease. Even if asymptomatic with normal blood glucose levels, ketone levels should be checked regularly, and medicines should only be reintroduced after the clinical situation has stabilised and normal oral intake has been achieved.

Variable rate insulin infusion

Many diabetics who are having elective surgery may have been hospitalised the night before and started on a VRII (also known as a sliding scale). While VRII may maintain tight glucose control, it comes with hazards such as hyper- and hypoglycemia due to improper infusion rates or insufficient monitoring, rebound hyperglycemia and possibly ketoacidosis if the infusion is discontinued too soon, fluid overload, and electrolyte problems. According to NaDIA statistics, VRII is used needlessly in 6.5 percent of all inpatients.

It is feasible to eliminate the usage of VRII while still maintaining adequate glycemic control with careful optimisation and personalised planning. In the following situations, however, VRII may be preferable: individuals with T1D or T2D having surgery with a fasting duration of >1 meal

Patients with T1D who have not received background/basal insulin have unsatisfactory diabetes control (HbA1c >69 mmol/mol) and need emergency surgery have sustained hyperglycemia in the perioperative phase in the setting of acute decompensation.

The CPOC guideline discusses the realities of VRII usage, including how to adapt if there are hypoglycemic risk factors (such as chronic kidney disease, low body weight or low total daily insulin).

Continuous subcutaneous insulin infusions

Insulin pump treatment, also known as continuous subcutaneous insulin infusions (CSII), provides rapid acting insulin subcutaneously constantly from a refillable storage reservoir with boluses provided by the patient at mealtimes. Around 15% of T1D patients utilise CSII to control their diabetes, and its usage is increasing.

Because CSII patients do not take long-acting insulin, metabolic decompensation may develop quickly if their insulin supply is disrupted. If a patient is unable to handle their pump on their own, an alternate insulin delivery should be employed instead of CSII. 16 Insulin pumps are not approved for use near diathermy or imaging instruments, thus most surgical procedures require patients to convert to a VRII or subcutaneous insulin regimen. Patients, on the other hand, may choose to continue utilising CSII throughout the perioperative phase, which might help them avoid needless VRII usage and complications. However, since many non-specialists are unfamiliar with CSII, using it perioperatively might be dangerous unless closely monitored by the diabetes team.

Returning to the ward and preparing for discharge

After surgery, communication from the theatre staff to the ward team might be a risk, and handover should include drugs delivered in theatre, CBG level on leaving the recovery area, and diabetes management plan for ward-based care.

Blood glucose levels should stay in the desired range of 6–12 mmol/L after surgery. The goal is to return to a regular diet and diabetic medication as soon as clinically safe. Early 'DREAMing' (DRinking, EAting, and Mobilizing), which is the cornerstone of postoperative care, may help with this. Anti-emetics and analgesics should be used appropriately, intravenous fluids should be avoided if needs can be met orally or enterally, and mobilisation should be encouraged.

Patients should be encouraged to self-manage their diabetes and participate in diabetes care choices. If the discharge delays are caused by diabetes, the diabetes expert team should be consulted. On release, timely contact with all providers is critical, particularly in primary care. This is especially crucial if diabetes treatment has changed or if diabetes management has been a source of concern during the stay.

Reference-

New guidance on the perioperative management of diabetes

Bonnie Grant, Tahseen A Chowdhury

Clinical Medicine Jan 2022, 22 (1) 41-44; DOI: 10.7861/clinmed.2021-0355

https://www.rcpjournals.org/content/clinmedicine/22/1/41