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1/2/2018

Prevention of Complications in Women with Diabetes Undergoing Surgery

Diabetes mellitus (DM) is a common and increasingly prevalent chronic medical condition affecting one in 11 persons worldwide. Approximately half of these cases are undiagnosed. 

Routine screening for diabetes is not recommended at time of preoperative evaluation.  However, it is appropriate to test patients who meet American Diabetes Association (ADA) or U.S. Preventive Services Task Force (USPSTF) screening criteria and who have not been recently tested.  If DM is diagnosed preoperatively, the patient should be evaluated for the presence of diabetes-related complications. Preoperative diagnostic testing should include serum electrolyte levels, urinalysis, and electrocardiogram to identify undiagnosed metabolic abnormalities, nephropathy, and cardiac ischemia. Hemoglobin A1C should be checked within 3 months of scheduled surgery. Consideration should be given to postponing elective surgery in patients with a hemoglobcin A1C greater than or equal to 8% which has been associated with poor surgical outcomes in some studies.

In diabetic patients, surgical stress leads to worsening insulin resistance, decreased peripheral glucose utilization, impaired insulin secretion, and increased protein catabolism causing hyperglycemia and possible ketosis in Type 1 diabetics. General anesthesia is associated with a larger stress response compared with regional anesthesia. The extent of this response is also dependent on the complexity and duration of the surgery as well as postoperative factors. A preoperative risk assessment should be performed for patients at high risk for ischemic heart disease and with autonomic neuropathy or renal failure.

Glycemic control is critical, and is covered in a separate Pearl (see Glycemic Control in Women with Diabetes Undergoing Surgery).

Multiple strategies exist to prevent cardiovascular complications in a patient with diabetes. Patients with indications for chronic use of beta-blockers (hypertension, atrial fibrillation, angina, heart failure, or a history of myocardial infarction) should be continued on them preoperatively. Diabetic patients with chronic hypertension should have their blood pressure optimized. Since diabetes confers an increased risk of cardiovascular events, lipid-lowering therapy should be considered preoperatively.

Patients with diabetic gastroparesis should receive a prokinetic agent (e.g. metoclopramide) prior to the administration of general anesthesia to decrease aspiration risk. Attempts should be made to use multi-modal analgesia for pain control and minimize opioid use to prevent additional decreased motility.

It is important to avoid hypotension in patients with diabetic kidney disease (formerly referred to as nephropathy). Surgery results in large fluid shifts, which can lead to ischemic renal injury, and which is more likely in the setting of pre-existing diabetic kidney disease.  Non-steroidal anti-inflammatory drugs (NSAIDS) should be used cautiously.

Patients with diabetic autonomic neuropathy are at increased risk of peripheral neuropathy. Surgical positioning and cushioning should be optimized.

Postoperatively, diabetic patients have an increased risk of infections and wound complications. Prevention strategies include attention to aseptic technique and adherence to proper antibiotic prophylaxis with appropriate dose adjustment for weight.  Because patients with diabetes are at risk for poor wound healing, surgeons should optimize intraoperative temperature control with the use of blankets or forced-air warming systems. Hypothermia can lead to peripheral insulin resistance, hyperglycemia, decreased wound healing, and infection.

Further Reading:

Preoperative Considerations. In: Hoffman BL, Schorge JO, Halvorson LM, Hamid CA, Corton MM, Schaffer JI. eds. Williams Gynecology, 4e. McGraw Hill; 2020.

American Diabetes Association. Standards of Medical Care in Diabetes- 2022. Diabetes Care 2022 Jan; 45(Supplement 1): S244-S253. Available at: https://doi.org/10.2337/dc22-S016 accessed 1/1/23.

Companion Pearl: Glycemic Control in Women with Diabetes Undergoing Surgery

Initial Approval:  January 2, 2018. Reaffirmed September 2019 & May 2021.  Minor Revision January 2023

 

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