What are the guidelines for fluid resuscitation in patients with diabetes mellitus (Diabetes Mellitus) undergoing surgery?

Guidelines for Fluid Resuscitation in Patients with Diabetes Mellitus Undergoing Surgery

For patients with diabetes mellitus undergoing surgery, goal-directed fluid therapy should be used for high-risk patients or high-risk procedures, while a more restrictive approach with balanced crystalloid solutions is recommended for routine cases. 1

Preoperative Fluid Management

• Ensure adequate hydration before surgery by allowing clear fluid intake up to 2 hours before anesthesia induction and solid food up to 6 hours preoperatively 1
• Avoid excessive fasting to prevent preoperative fluid depletion 1
• Administer preoperative carbohydrate drinks (400ml of 12.5% maltodextrin solution) 2-3 hours before anesthesia to reduce insulin resistance and improve metabolic state 2, 1
• For diabetic patients, carbohydrate drinks can be given along with their usual diabetic medication, though evidence for this practice is more limited 1, 2
• Correct any existing fluid and electrolyte imbalances before surgery to ensure the patient enters the operating room in a euvolemic state 1
• Monitor preoperative blood glucose levels, with a target range of 5-10 mmol/L (0.9-1.8 g/L) 1

Intraoperative Fluid Management

• Administer crystalloids at a rate of 1-4 ml/kg/h as maintenance fluid during surgery 1
• Use balanced crystalloid solutions (e.g., Hartmann's solution) rather than 0.9% saline to reduce the risk of hyperchloremic acidosis 1, 3
• For high-risk diabetic patients or those undergoing high-risk procedures, implement goal-directed fluid therapy (GDFT) using minimally invasive cardiac output monitoring 1
• Administer fluid boluses (200-250 ml) only when there is objective evidence of hypovolemia (>10% fall in stroke volume) 1
• Monitor blood glucose levels hourly during lengthy procedures, maintaining levels between 5-10 mmol/L (0.9-1.8 g/L) 1
• Postpone non-emergency surgery if blood glucose exceeds 16.5 mmol/L (3 g/L) 1

Postoperative Fluid Management

• Encourage early oral intake as soon as the patient is awake and free of nausea 1
• Discontinue intravenous fluids once adequate oral intake is established 1
• If intravenous fluids are required postoperatively, administer maintenance fluids at 25-30 ml/kg/day with no more than 70-100 mmol sodium/day 1
• Replace ongoing losses (e.g., vomiting, high stoma output) on a like-for-like basis in addition to maintenance requirements 1
• For patients receiving epidural analgesia who become hypotensive, use vasopressors rather than indiscriminate fluid boluses once normovolemia is confirmed 1
• Continue monitoring blood glucose levels postoperatively, with immediate intervention for hypoglycemia (<3.3 mmol/L or 0.6 g/L) or hyperglycemia (>10 mmol/L or 1.8 g/L) 1

Special Considerations for Diabetic Patients

• Patients with poorly controlled diabetes (high HbA1c) have significantly worse outcomes, including increased risk of infectious complications and mortality 1
• The highest risk group for perioperative complications are patients without diagnosed diabetes who develop postoperative hyperglycemia 1
• For patients with type 1 diabetes or insulin-dependent type 2 diabetes, resume previous insulin regimen once oral intake is established, adjusting doses based on inpatient requirements 1
• For hyperglycemia >16.5 mmol/L (3 g/L), check for ketosis and administer rapid-acting insulin accordingly 1
• In diabetic ketoacidosis, balanced electrolyte solutions may be preferable to 0.9% saline for fluid resuscitation, as they resolve DKA faster and cause less hyperchloremia 4

Pitfalls and Caveats

• Avoid fluid overload, as excess fluid administration can lead to tissue edema, impaired pulmonary gas exchange, decreased tissue oxygenation, and compromised microvascular perfusion 1
• Excessive use of 0.9% saline can cause hyperchloremic acidosis, decreased renal blood flow, and impaired gastric motility 1, 3
• Fluid deficit or overload of as little as 2.5L can increase postoperative complications and prolong hospital stay 1
• Patients with diabetic neuropathy may have delayed gastric emptying for solids, potentially increasing aspiration risk, though fluid emptying is generally normal 1
• For ambulatory surgery in diabetic patients, management depends on the number of meals missed, with specific protocols for timing of medication administration 1