What are the recommendations for optimizing a patient with an elevated Hemoglobin A1C (HbA1C) level of 8.7% undergoing Transurethral Resection of the Prostate (TURP) with anesthesia?

Optimization of a Patient with A1C 8.7% for TURP with Anesthesia

For a patient with an A1C of 8.7% undergoing TURP with anesthesia, the target A1C should be <8% before proceeding with elective surgery to reduce perioperative complications. 1

Preoperative Assessment and Management

• The A1C goal for elective surgeries should be <8% (<63.9 mmol/mol) whenever possible to reduce the risk of surgical complications 1
• For patients with A1C between 8-9%, consultation with a diabetologist is recommended before surgery to optimize glycemic control 1
• Patients with poorly controlled diabetes (A1C >8.7%) have higher rates of surgical site infections, with studies showing infection rates of 35.3% in patients with A1C ≥7.0% compared to 0% in those with A1C <7.0% 2
• Elevated A1C levels are associated with increased risk of myocardial infarction and deep sternal wound infections, with each unit increase in A1C 3

Perioperative Protocol

Day of Surgery

• Hold metformin on the day of surgery 1
• If patient is on SGLT2 inhibitors, these should have been discontinued 3-4 days before surgery 1
• Hold any other oral glucose-lowering agents the morning of surgery 1
• If patient is on insulin, administer 75-80% of long-acting analog insulin dose or 50% of NPH dose 1
• Monitor blood glucose every 2-4 hours while NPO (nothing by mouth) 1
• Target blood glucose range in the perioperative period should be 100-180 mg/dL (5.6-10.0 mmol/L) 1

During Surgery

• Continuous glucose monitoring should not be used alone for glucose monitoring during surgery 1
• Administer short- or rapid-acting insulin as needed to maintain target glucose range 1

Postoperative Management

• For patients with A1C between 8-9%, resume previous treatment with adjustments 1:

  • If on oral antidiabetics only: Resume at same doses if no contraindication, consider adding basal insulin 1
  • If on oral antidiabetics plus insulin: Resume oral agents at same doses (if renal function permits) and continue basal insulin with adjusted dose 1

• Monitor blood glucose levels regularly in the postoperative period to detect hyperglycemia 1

• For persistent hyperglycemia (>11 mmol/L or 2 g/L), implement basal-bolus insulin regimen 1

Common Pitfalls to Avoid

• Attempting to achieve overly aggressive A1C targets (<7%) preoperatively may delay necessary surgery and may not be achievable for many patients 4
• Studies show that only 59% of patients with A1C >7% were able to achieve an A1C ≤7% despite medical intervention, while 70% could achieve A1C ≤8% 4
• Both very low A1C (≤6%) and very high A1C (>8%) are associated with increased cardiovascular events, suggesting that moderate control is optimal 5
• Failing to adjust insulin doses based on steroid administration during perioperative period can lead to significant hyperglycemia 1

Discharge Planning

• For patients with A1C between 8-9%, schedule a follow-up consultation with a diabetologist after discharge 1
• Provide clear instructions for resuming diabetes medications and insulin regimen 1
• Ensure the patient understands the importance of continued glucose monitoring at home 1

By following these recommendations, you can optimize perioperative outcomes for patients with elevated A1C levels undergoing TURP with anesthesia while minimizing the risk of complications.