What are the preoperative clearance recommendations for a patient with uncontrolled diabetes (A1C 9.6%) undergoing a lumbar fusion?

Preoperative Clearance Recommendations for a Patient with Uncontrolled Diabetes (A1C 9.6%) Undergoing Lumbar Fusion

The patient with an A1C of 9.6% should be advised to postpone the elective lumbar fusion until their A1C is reduced to below 8% to minimize perioperative complications. 1

Risk Assessment and Glycemic Targets

• A preoperative risk assessment should be performed for patients with diabetes who are at high risk for ischemic heart disease, autonomic neuropathy, or renal failure 1
• The recommended A1C target for elective surgeries is <8% (<64 mmol/L) whenever possible 1
• The target blood glucose range in the perioperative period should be 100-180 mg/dL (5.6-10.0 mmol/L) within 4 hours of surgery 1
• Continuous glucose monitoring (CGM) should not be used alone for glucose monitoring during surgery 1

Rationale for Postponing Surgery

With an A1C of 9.6%, this patient has significantly uncontrolled diabetes, which increases the risk of:

• Higher mortality rates 1
• Increased infection risk 1
• Prolonged hospital length of stay 1
• Surgical complications due to impaired wound healing 1

Preoperative Optimization Recommendations

If surgery cannot be postponed, implement the following measures:

• Refer to diabetes management team for intensive glucose control 1
• Establish a structured plan to lower A1C prior to surgery 1
• Monitor capillary blood glucose levels frequently in the days preceding surgery 1
• Aim for blood glucose <180 mg/dL (10 mmol/L) before the intervention 1

Medication Management Before Surgery

• Metformin: Hold on the day of surgery 1
• SGLT2 inhibitors: Discontinue 3-4 days before surgery 1
• Other oral glucose-lowering agents: Hold on the morning of surgery 1
• NPH insulin: Give half of the usual dose 1
• Long-acting insulin analogs: Give 75-80% of usual dose 1
• Insulin pump: Adjust basal rates based on the type of diabetes and clinical judgment 1

Intraoperative and Perioperative Management

• Monitor blood glucose every 2-4 hours while the patient is NPO 1
• Administer short-acting or rapid-acting insulin as needed for hyperglycemia 1
• Consider that compared with usual dosing, a reduction of insulin given the evening before surgery by 25% may achieve better perioperative blood glucose control with lower hypoglycemia risk 1
• For non-cardiac general surgery patients, basal insulin plus premeal short-acting or rapid-acting insulin (basal-bolus) coverage has been associated with improved glycemic outcomes compared to correction-only insulin coverage 1

Special Considerations

• Surgical stress and counterregulatory hormone release increase the risk of hyperglycemia 1
• Stricter perioperative glycemic targets (<80 mg/dL) are not advised as they do not improve outcomes and are associated with more hypoglycemia 1
• There are limited data on the safe use and influence of GLP-1 receptor agonists in the perioperative period 1

Key Pitfalls to Avoid

• Failing to identify and address hypoglycemia risk factors: Previous episodes of hypoglycemia during hospitalization increase the risk for subsequent events 1
• Not accounting for steroid use during surgery: If steroids will be used, anticipate higher insulin requirements (up to 40-60% more) 1
• Inadequate monitoring: Ensure blood glucose is checked at least every 2-4 hours while NPO to prevent severe hyperglycemia or hypoglycemia 1