Epidural Injections with Elevated HbA1c (8.9%)
An epidural injection should not be held solely based on an HbA1c of 8.9%, but this level indicates poor glycemic control that warrants diabetology consultation before the procedure.
Assessment of Glycemic Control
The HbA1c value of 8.9% indicates:
- Suboptimal glycemic control (target for most diabetic patients is around 7%) 1
- Average plasma glucose of approximately 240 mg/dL (13.5 mmol/L) 1
- Falls into the "HbA1c between 8 and 9%" category in perioperative management guidelines 1
Decision Algorithm for Epidural Injections
For HbA1c between 8-9%:
- Proceed with the epidural injection
- Arrange for diabetology consultation after the procedure 1
- Monitor blood glucose levels closely during the perioperative period
When to hold epidural injections:
- HbA1c >9% (indicates significantly poor control)
- Presence of ketosis
- Unstable blood sugar levels (>11 mmol/L or 2 g/L)
- Acute hyperglycemic crisis
Rationale for Proceeding with Caution
- An HbA1c of 8.9% indicates chronic poor glycemic control but is not an absolute contraindication for epidural injections
- Guidelines suggest that patients with HbA1c between 8-9% should have diabetology consultation, but do not recommend postponing procedures 1
- The threshold for significantly increased procedural risk appears to be HbA1c >9% 1
Post-Procedure Management
For patients with HbA1c between 8-9%:
- Arrange consultation with a diabetologist for intensification of therapy 1
- Resume previous treatment with potential adjustments
- Consider adding or adjusting insulin therapy based on individual needs
- Monitor for post-procedure glycemic fluctuations
Important Considerations and Caveats
- Infection risk: Poor glycemic control increases infection risk, but an HbA1c of 8.9% alone is not a definitive contraindication
- Vascular complications: Elevated HbA1c is associated with increased adverse limb events in patients with peripheral arterial disease 2
- Measurement reliability: Ensure the A1C test was performed using a method certified by the National Glycohemoglobin Standardization Program (NGSP) 1
- Hemoglobinopathies: In patients with hemoglobinopathies or abnormal red cell turnover, A1C may not be reliable 1
Clinical Pearls
- Always check capillary blood glucose immediately before the procedure regardless of HbA1c
- Document the patient's baseline diabetic status and treatment regimen
- Establish a follow-up plan for diabetes management post-procedure
- Consider the specific type of diabetes (Type 1 vs Type 2) when planning perioperative management
Remember that while HbA1c provides valuable information about long-term glycemic control, it does not reflect acute glycemic status, which should also be assessed before proceeding with an epidural injection.