What is diabetes and how is it managed, especially in relation to anesthesia?

From the Guidelines

Diabetes management during anesthesia requires careful planning and monitoring to prevent complications, with a focus on maintaining blood glucose levels between 140-180 mg/dL (7.8-10 mmol/L) during surgery, as recommended by the most recent guidelines 1.

Definition and Pathophysiology of Diabetes

Diabetes is a chronic metabolic disorder characterized by elevated blood glucose levels due to either insufficient insulin production (Type 1) or ineffective insulin use (Type 2) 1. The chronic hyperglycemia of diabetes is associated with long-term damage, dysfunction, and failure of various organs, especially the eyes, kidneys, nerves, heart, and blood vessels.

Signs and Symptoms of Diabetes

Symptoms of marked hyperglycemia include polyuria, polydipsia, weight loss, sometimes with polyphagia, and blurred vision 1. Impairment of growth and susceptibility to certain infections may also accompany chronic hyperglycemia.

Diagnosis of Diabetes

The diagnosis of diabetes is based on the degree of hyperglycemia, which may change over time, depending on the extent of the underlying disease process 1. A disease process may be present but may not have progressed far enough to cause hyperglycemia.

Treatment of Diabetes

The treatment of diabetes involves lifestyle modifications, such as diet and exercise, as well as medications, including oral antidiabetic agents and insulin 1. The management of diabetes during anesthesia requires careful planning and monitoring to prevent complications, with a focus on maintaining blood glucose levels between 140-180 mg/dL (7.8-10 mmol/L) during surgery, as recommended by the most recent guidelines 1.

Anesthesia Considerations

Patients with diabetes should continue their oral antidiabetic medications until the day before surgery, with metformin typically stopped 24-48 hours before to prevent lactic acidosis 1. Insulin regimens are usually modified, with long-acting insulin reduced to 50-80% of the usual dose on the morning of surgery, while short-acting insulin is held. During surgery, blood glucose should be monitored every 1-2 hours, maintaining levels between 140-180 mg/dL (7.8-10 mmol/L) 1. If needed, intravenous insulin may be administered using protocols such as starting with 0.1 units/kg/hour for readings above 180 mg/dL, adjusting based on hourly measurements. Dextrose-containing fluids (D5W or D10W) should be available to treat hypoglycemia. Postoperatively, regular monitoring continues until the patient resumes normal eating patterns, with subcutaneous insulin restarted once oral intake is established.

Some key considerations for anesthesia in diabetic patients include:

• Preoperative assessment of glycaemic control and adjustment of treatments accordingly 1
• Management of antidiabetic therapy, including the use of insulin pumps and oral antidiabetic agents 1
• Monitoring of blood glucose levels during surgery and adjustment of insulin therapy as needed 1
• Use of dextrose-containing fluids to treat hypoglycemia 1
• Postoperative monitoring and management of blood glucose levels until the patient resumes normal eating patterns 1

From the FDA Drug Label

Diabetes occurs when the pancreas does not make enough insulin to meet your body's needs Insulin is a hormone produced by the pancreas, a large gland that lies near the stomach. This hormone is necessary for the body's correct use of food, especially sugar. To control your diabetes, your doctor has prescribed injections of insulin products to keep your blood glucose at a near-normal level. Studies have shown that some chronic complications of diabetes such as eye disease, kidney disease, and nerve disease can be significantly reduced if the blood sugar is maintained as close to normal as possible.

Diabetes Definition and Pathophysiology: Diabetes is a condition where the pancreas does not produce enough insulin, a hormone necessary for the body's correct use of food, especially sugar. Signs and Symptoms: Not directly mentioned in the label. Diagnosis: Not directly mentioned in the label. Treatment: Involves injections of insulin products to keep blood glucose at a near-normal level, as well as a balanced diet and regular exercise. Anaesthesia Considerations: Not directly mentioned in the label, however, it is implied that patients with diabetes require close and constant cooperation with their doctor to manage their condition, which may be relevant when considering anesthesia 2.

From the Research

Definition and Pathophysiology of Diabetes

• Diabetes mellitus is a chronic heterogeneous metabolic disorder with complex pathogenesis, characterized by elevated blood glucose levels or hyperglycemia 3.
• It results from abnormalities in either insulin secretion or insulin action or both, leading to carbohydrate, fat, and protein metabolic dysfunctions 3, 4.
• Hyperglycemia serves as the primary biomarker for the diagnosis of diabetes and can lead to various microvascular and macrovascular diabetic complications 3.

Signs and Symptoms of Diabetes

• The chronic hyperglycemia of diabetes mellitus is associated with long-term damage, dysfunction, and failure of various organs, especially the eyes, kidneys, nerves, heart, and blood vessels 4.
• Common signs and symptoms of diabetes include increased thirst and urination, fatigue, blurred vision, and slow healing of cuts and wounds.

Diagnosis of Diabetes

• Hyperglycemia is the primary biomarker for the diagnosis of diabetes, and diagnosis is typically made through blood glucose tests, such as fasting plasma glucose or oral glucose tolerance tests 3, 4.
• Hemoglobin A1c (HbA1c) tests are also used to diagnose and monitor diabetes, with a target level of <6.5% recommended by the American Association of Clinical Endocrinologists and the European Association for the Study of Diabetes 5.

Treatment of Diabetes

• Medical nutrition therapy (MNT) and physical activity are the cornerstones of management of type 2 diabetes, with the goal of achieving normalization of blood glucose levels 5.
• Antidiabetic agents, including insulin, may be used in combination with MNT and physical activity to manage blood glucose levels, with the choice of therapy depending on the individual patient's needs and response to treatment 5, 6, 7.
• Combination therapy with oral diabetes medications, such as pioglitazone, metformin, and sulfonylurea, may be used to target different pathogenic mechanisms and manage both fasting and postprandial blood glucose levels 5, 6, 7.

Anesthesia Considerations in Diabetes

• Patients with diabetes require careful management during anesthesia, with consideration of their blood glucose levels, medication regimen, and potential complications such as hypoglycemia or hyperglycemia.
• Anesthesia providers should work closely with the patient's healthcare team to develop a plan for managing their diabetes during surgery and anesthesia.