Is prediabetes (impaired glucose regulation) a minor or intermediate risk factor for surgical procedures?

From the Guidelines

Prediabetes is an intermediate risk factor for surgery, not a minor one, as it can lead to increased surgical risks, including impaired wound healing, infection, and cardiovascular complications, although these risks are generally less severe than for patients with diagnosed diabetes. Patients with prediabetes have increased surgical risks compared to those with normal blood glucose levels, and these risks should be carefully managed perioperatively [ 1 ]. According to the 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM guideline for perioperative cardiovascular management for noncardiac surgery, preoperative hemoglobin A1c (HbA1C) testing is reasonable in patients with or at risk for diabetes who are scheduled for elective noncardiac surgery if it has not been performed in ≤3 months [ 1 ].

Key Considerations for Perioperative Management

• Blood glucose monitoring is essential in patients with prediabetes undergoing surgery
• Maintaining glucose levels below 180 mg/dL is recommended to reduce the risk of perioperative complications [ 1 ]
• Temporary insulin therapy may be necessary if glucose levels rise significantly
• Postoperative monitoring for signs of infection and delayed wound healing is crucial
• Referral to diabetes prevention programs should be considered to prevent or delay progression to type 2 diabetes

The management of perioperative hyperglycemia is imperative, and the optimal blood glucose targets for intraoperative glycemic control are not well-defined [ 1 ]. However, emerging data suggest that maintaining glucose levels between 100-180 mg/dL can help reduce the risk of perioperative complications [ 1 ]. Additionally, the use of SGLT2 inhibitors, such as canagliflozin, dapagliflozin, and empagliflozin, should be discontinued 3-4 days before surgery to reduce the risk of perioperative metabolic acidosis [ 1 ].

From the Research

Prediabetes as a Risk Factor for Surgery

• Prediabetes is considered an important disease process with several perioperative implications, affecting approximately one third of the United States population 2.
• The prevalence of prediabetes in surgical patients is higher due to associated micro and macrovascular complications that result in the need for subsequent surgical procedures 2.
• Prediabetes is not considered benign, as it is a risk factor for type 2 diabetes and is associated with micro and macrovascular complications 3.

Perioperative Management of Prediabetes

• A careful preoperative evaluation of patients with prediabetes is essential to reduce perioperative mortality and morbidity 2.
• Preoperative evaluation involves optimization of preoperative comorbidities and antidiabetic medication regimens to avoid unintentional hypoglycemic and hyperglycemic episodes during the perioperative period 2.
• Intraoperative glycemic control goals may vary, but guidelines suggest a glucose range in the operating room should be between 140 mg/dL to 180 mg/dL 2.

Risk of Complications in Surgical Patients with Prediabetes

• Prediabetes is associated with increased risk of diabetes, cardiovascular events, and mortality 4.
• Diabetic patients, including those with prediabetes, may be at increased risk of complications and poor visual outcomes after cataract surgery 5.
• Preoperative risk factors such as age, retinal diseases, hypoglycemic medications, and hemoglobin A1C levels may play a role in patient outcomes following surgery 5.

Classification of Prediabetes as a Risk Factor

• Prediabetes can be considered an intermediate risk factor for surgery, as it is associated with increased risk of complications and poor outcomes, but the risk is not as high as that associated with diabetes 2, 3, 4.
• The risk of complications in surgical patients with prediabetes can be mitigated with careful preoperative evaluation and management, as well as optimization of antidiabetic medication regimens and intraoperative glycemic control 2, 5.