Can a 76-year-old patient with uncontrolled diabetes undergo eye surgery in an ambulatory surgical center (ASC) under local (LA) or regional anesthesia (RA) or general anesthesia (GA)?

Management of a 76-Year-Old Patient with Uncontrolled Diabetes for Eye Surgery in an Ambulatory Surgical Center

Yes, a 76-year-old patient with uncontrolled diabetes can undergo eye surgery in an ambulatory surgical center under local or regional anesthesia, but specific preoperative glycemic control measures must be implemented to ensure safety. 1

Preoperative Assessment and Clearance

• Preoperative evaluation for diabetic patients considering ambulatory surgery should include assessment of glycemic control, with target HbA1c between 6-8% and blood glucose between 5-10 mmol/L (0.9-1.8 g/L) 1, 2
• If the patient's HbA1c is >8% or blood glucose is >16.5 mmol/L (3 g/L) on the day of surgery, elective eye surgery should be postponed and the patient referred to a diabetologist for improved glycemic control 1, 2
• Eye surgery is particularly well-suited for ambulatory settings in diabetic patients, as vascular damage often affects the eye but doesn't necessarily require extended hospitalization 2

Anesthesia Considerations

• Local or regional anesthesia is preferred over general anesthesia for diabetic patients undergoing eye surgery, as it minimizes glycemic fluctuations and allows for quicker return to normal eating patterns 2
• If general anesthesia is required, careful glycemic monitoring must be implemented with hourly blood glucose checks during the procedure 2
• No specific premedication is required for diabetic patients undergoing eye surgery in an ambulatory setting 2

Perioperative Management

• Upon admission to the ambulatory surgical center, a peripheral venous line should be inserted, but glucose infusion is only necessary if resumption of oral feeding will be delayed 2
• Capillary blood glucose should be measured on arrival and monitored hourly during the procedure, especially if surgery is lengthy 2
• An insulin (ultra-rapid analogue) bolus should be administered if blood glucose exceeds 10 mmol/L (1.8 g/L) 2
• Diabetic patients should be given priority on the surgical list to minimize fasting time 2

Medication Management

• If surgery is short and the patient can be transferred to the discharge room before 10 am, breakfast can be served afterward with morning medications 2
• For later procedures (10 am to noon), the patient should not take usual morning medications before going to the hospital but should take them upon arrival with a glucose infusion (G 10% 40 mL/h) 2
• For afternoon procedures, patients should have a light breakfast before coming to the hospital and take their usual medications 2

Postoperative Considerations

• Oral feeding should be resumed as soon as possible after surgery 2
• Regular blood glucose monitoring should continue postoperatively 2
• If blood glucose remains between 5-10 mmol/L (0.9-1.8 g/L), regular treatments can be resumed at usual times 2
• If blood glucose exceeds 10 mmol/L (1.8 g/L), the patient should remain in the facility for corrective subcutaneous insulin boluses until glucose levels decrease to target range 2
• If blood glucose exceeds 16.5 mmol/L (3 g/L), discharge should be contraindicated and the patient admitted to hospital for intravenous insulin therapy 2

Special Considerations for Eye Surgery

• Diabetic patients are at higher risk for anterior capsular fibrosis and contracture following cataract surgery 2
• Careful monitoring for postoperative complications such as diabetic macular edema is essential 3
• Implementing a standardized diabetic algorithm for ophthalmology surgery patients can improve safety, operating room efficiency, and decrease costs 4

Common Pitfalls and Caveats

• Failure to check HbA1c preoperatively may lead to unexpected perioperative complications 1
• Assuming that drowsiness is solely due to anesthesia rather than possible hypoglycemia 5
• Neglecting to monitor for postoperative hypoglycemia, especially in patients who may have hypoglycemia unawareness 5
• Underestimating the risk of ocular complications in diabetic patients undergoing eye surgery 6, 3