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4/1/2018

Glycemic Control in Diabetic Patients Undergoing Gynecologic Surgery

Patients with diabetes undergoing surgery are at increased risk of morbidity and mortality from their hypermetabolic stress response, preoperative catabolic state, altered nutritional status, changes in circulation, immobility, and glucose and electrolyte derangements.

As morbidity increases dramatically when preoperative blood glucose levels are elevated, all patients with diabetes should have an HgbA1C checked within three months of their intended procedure.    Prior to surgery, care should be coordinated with the patient’s primary care provider or endocrinologist and an anesthesia consultation obtained to optimize glycemic control and other medical comorbidities. When possible, the patient’s diet and medications should be adjusted so they maintain a predominantly euglycemic state in the weeks before surgery.  Fasting and postprandial blood glucoses should be checked as necessary to achieve euglycemia.

The goal for the day of surgery is to avoid both hypoglycemia and excessive hyperglycemia. Patients with Type 1 diabetes may enter a keto acidotic state even at low levels of hyperglycemia. Cancellation of surgery should be considered in non-emergent cases where blood glucoses are 400-500 mg/dL.

No standardized, evidence-based algorithm for diabetes management exists for gynecologic surgery. Due to the risk of metabolic acidosis, metformin and other oral hypoglycemic agents should be withheld the day of surgery.  On the morning of surgery, the patient should receive 50% of their usual NPH dose or 75-80% of their usual long-acting insulin analog (e.g. glargine or detemir) or pump basal insulin dose.

Surgery induces a stress response with catecholamine and cortisol release, which reduces sensitivity to insulin. This induced catabolic state can lead to keto- and gluconeogenesis as well as the breakdown of glucagon, proteins, and fats, leading to hyperglycemia and ketosis.  To manage this during surgery, the patient should be placed on a variable rate intravenous infusion of insulin or a sliding scale protocol if they will miss more than one meal. Medium and short acting insulins can be used for minor procedures. Insulin infusion is preferred for longer, more complex procedures. Type 1 diabetic patients should be maintained with a basal rate. Active evaluation and management of blood glucose intraoperatively is important to counteract the physiologic changes inherent to the use of anesthetics, sedatives, and analgesics.

In the perioperative period, the target glucose range should avoid hypo- or hyperglycemia, as this has been associated with lower rates of mortality.  Tighter glycemic control does not appear to improve outcomes and risks hypoglycemia.    Blood glucose monitoring should occur at least every 2-4 hours while patients remain NPO with additional short-acting insulin administered as needed.

Some medications commonly used in the peri-operative period can influence glycemic control. Etomidate, benzodiazepines, and opiates typically decrease the hyperglycemic response while most volatile anesthetic agents increase it. Regional anesthesia use is preferred because it has less impact on glucose and insulin metabolism.

If available, a diabetes specialist team should be utilized for care in the post-operative period. The patient’s usual diabetes management should be resumed as soon as feasible, generally once she is eating well.  Diet should be advanced the same was as in nondiabetic patients.

Further reading:

American Diabetes Association. Diabetes Care in the Hospital:  Standards of Medical Care in Diabetes 2022; Diabetes Care. 2018 Jan;41(Suppl 1):S144-S151. doi: 10.2337/dc18-S014. Available at: https://care.diabetesjournals.org/content/41/Supplement_1/S144. Accessed 1/8/18.

Joint British Diabetes Societies for inpatient care, Management of adults with diabetes undergoing surgery and elective procedures: improving standards. Available at: https://www.diabetes.org.uk/resources-s3/2017-09/Surgical%20guideline%202015%20-%20summary%20FINAL%20amended%20Mar%202016.pdf Accessed 7/8/19.

Duggan EW, Carlson K, Umpierrez GE. Perioperative Hyperglycemia Management: An Update. Anesthesiology. 2017 Mar;126(3):547-560. doi: 10.1097/ALN.0000000000001515.

Companion Pearl:  Prevention of Complications in Women with Diabetes Undergoing Surgery

Initial approval 1/2018. Revised July 2019. Reaffirmed March 2, 2021. Revised September 2022

 

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