From the Guidelines
Preoperative assessment for patients with diabetes mellitus (DM) and hypertension (HTN) should focus on optimizing these conditions to reduce perioperative complications, with a goal of achieving fasting blood glucose levels between 100-180 mg/dL and HbA1c <8% before elective surgery, as recommended by the most recent guidelines 1.
Key Considerations for Diabetes Management
- A preoperative risk assessment should be performed for people with diabetes who are at high risk for ischemic heart disease and those with autonomic neuropathy or renal failure 1.
- Metformin should be held on the day of surgery, while SGLT2 inhibitors should be discontinued 3-4 days before surgery 1.
- Other oral glucose-lowering agents should be held the morning of surgery or procedure, and insulin dose reductions include NPH insulin to one-half of the dose or long-acting basal insulin analogs 1.
- The blood glucose goal in the perioperative period should be 100–180 mg/dL (5.6–10.0 mmol/L) within 4 h of the surgery, and continuous glucose monitoring (CGM) should not be used alone for glucose monitoring during surgery 1.
Key Considerations for Hypertension Management
- For hypertension, maintain blood pressure below 140/90 mmHg preoperatively, and consider holding ACE inhibitors and ARBs 24 hours before surgery if concerns about intraoperative hypotension exist 1.
- Most antihypertensive medications should be continued through the morning of surgery, including beta-blockers (metoprolol, atenolol), ACE inhibitors, ARBs, and calcium channel blockers 1.
- Additional preoperative testing should include basic metabolic panel, complete blood count, ECG for patients over 65 or with cardiac history, and possibly cardiac stress testing for high-risk patients 1.
Overall Strategy
- The overall strategy for preoperative assessment and management of patients with DM and HTN should prioritize optimizing these conditions to reduce perioperative complications, while also considering the potential risks and benefits of different management strategies 1.
- By following these guidelines and considering the individual patient's needs and circumstances, healthcare providers can help reduce the risk of adverse events and improve outcomes for patients with DM and HTN undergoing surgery.
From the Research
Medical Preoperative Assessment for DM and HTN
Overview of HTN and DM
- Hypertension (HTN) and Diabetes Mellitus (DM) are two common comorbidities that can impact surgical outcomes 2, 3.
- The coexistence of HTN and DM increases the risk of cardiovascular disease and morbidity 3.
- A thorough preoperative assessment is crucial to identify patients with HTN and DM and to optimize their management before surgery.
Preoperative Assessment of HTN
- General recommendations for the perioperative management of patients with hypertensive disease have not changed significantly over the past 20 years 2.
- Total cardiovascular risk rather than blood pressure alone should determine the preoperative strategy for patients with HTN 2.
- Except for grade 3 hypertension, surgery should not be deferred based on an elevated blood pressure in the preoperative assessment 2.
Preoperative Assessment of DM
- DM is a significant risk factor for cardiovascular disease, and its management is crucial in the preoperative period 3, 4.
- The goal of blood pressure management in patients with DM is to achieve a blood pressure of less than 140/90 mmHg 3.
- Certain antihypertensive medications, such as calcium channel blockers and angiotensin-converting enzyme inhibitors, are suitable for patients with DM 5, 6.
Management of HTN and DM in the Preoperative Period
- A multidisciplinary approach is necessary to manage patients with HTN and DM in the preoperative period 2, 3.
- The choice of antihypertensive medication should be individualized based on the patient's pathophysiology and comorbidities 5, 6.
- Close monitoring of blood pressure and blood glucose levels is essential in the preoperative period to optimize patient outcomes 2, 3.