Stephen M. Schroeder, DPMsschroeder@osma1.com,     Sports Medicine Oregon, 7300 Southwest Childs Road, Suite B, Tigard, OR 97224, USA

Perioperative management of diabetic patients involves optimizing glycemic control and negotiating comorbidities to help reduce complications and obtain results on par with nondiabetics. These goals are usually achievable in the elective surgical setting, but they can be more difficult to control in urgent or emergent situations. Understanding and recognizing the comorbidities associated with diabetes is imperative for optimizing outcomes. Regulating hyperglycemia can reduce morbidity, mortality, and postoperative infections. Understanding the effects of cardiac and renal disease is also important. Taking a team approach in managing these complex patients leads to improved outcomes and is now considered the standard of care.

Keywords

Diabetes mellitus

Management

Glycemic control

Comorbidities

Key points

Introduction

The incidence of diabetes continues to escalate in the United States and throughout the world. Diabetes has deleterious affects on multiple body systems and is the leading cause of blindness, end-stage renal disease, and nontraumatic amputations.1 Peripheral neuropathy and vascular disease lead to lower extremity complications that correlate directly with higher morbidity and mortality. In addition, the sequelae of diabetes create complex scenarios that make treatment challenging. The disease is directly related to increased morbidity and length of stay in hospitals.2 It is estimated that up to 25% of hospitalized Americans have diabetes. Surgical patients are estimated to stay in house 45% longer and have 5 times higher mortality than nondiabetic patients.3

Some of the primary factors that put diabetic patients at higher risk are poor glycemic control, the existence of comorbidities, and failure to recognize the condition. Poor long-term and short-term blood sugar control has been shown to delay healing and increase the risk of postoperative infections throughout multiple specialties.4

Diabetic patients are often elderly with comorbidities including cardiovascular disease, impaired renal function, respiratory disease, and peripheral vascular disease.5 There is a 2-fold to 4-fold increase of cardiovascular disease in diabetic patients that may include hypertension, coronary artery disease, or stroke.6 Diabetic surgical patients often present with one or more of these conditions and need to be properly addressed in order to proceed safely with the planned procedure.

There is a common misconception that surgery should not be performed on diabetic patients for fear of complications and poor outcomes. Although certain aspects of diabetes can predispose patients to potential perioperative complications, improved understanding of the disease process combined with newer technology, a team-oriented approach, and better anesthesia techniques makes surgery a less harrowing proposition. This article focuses on perioperative management of diabetic patients. It gives advice on ways to prepare patients during this time in order to optimize outcomes for elective and nonelective procedures.

Perioperative assessment

Proper perioperative management of diabetic patients starts by identifying those with the disease state. Patients who have established medical care with a primary care physician (PCP) are typically identified. However, there is an increasing number of people in the United States without medical insurance, who do not have proper access to a PCP, and who may have unrecognized and untreated diabetes. Of the estimated 25 million Americans with diabetes, 7 million (28%) do not know they have it and only become aware when a complication arises,7 which is particularly problematic for patients requiring emergency surgery because hyperglycemia and other comorbidities cannot be properly managed before surgery, which may lead to increased complications.8 Patients with undocumented but suspected diabetes should be worked up by checking serum glucose and glycosylated hemoglobin A1c (HbA1c) levels before surgery.

Identification of these patients is done with a thorough history and physical examination. The history should detail symptoms of cardiac, neurologic, peripheral vascular (peripheral vascular disease [PVD]), retinal, and renal disease. It is important that patients with cardiac disease, PVD, or renal disease get proper preoperative clearance from their PCP or particular specialist before undergoing elective surgery. Proper referrals should be made before moving forward if they are not established with a PCP or specialist. Box 1 and Tables 1 and 2 detail elements that should be included in the preoperative work-up.

Perioperative management