What is the best course of action for an elderly female patient with hypertension (HTN) and diabetes mellitus (DM) who has uncontrolled blood pressure and hyperglycemia prior to elective surgery?

Adjust HTN and DM Medications - Do Not Postpone Surgery

The correct answer is B: Adjust her HTN and DM medications. This patient's blood pressure (160/95 mmHg) and glucose (9.1 mmol/L = 164 mg/dL) are moderately elevated but do not mandate postponement of elective surgery, and delaying surgery for one month to optimize these parameters offers no proven mortality or morbidity benefit compared to proceeding with appropriate perioperative management 1.

Why Not Postpone Surgery

The evidence does not support routine cancellation of elective surgery for this level of blood pressure or glucose elevation. The British Hypertension Society and Association of Anaesthetists explicitly state that "the lifelong risk of mortality and morbidity may be unaffected by postponing surgery for the assessment of cardiovascular risk by primary care and possible antihypertensive treatment," noting that each postponed month adds a 1% relative increase in cardiovascular risk due to patient aging 1.

• Blood pressure of 160/95 mmHg does not meet criteria for mandatory surgical postponement, as patients with DBP <110 mmHg can proceed safely 1
• The ACC/AHA guidelines recommend BP control to <130/80 mmHg is "reasonable" before elective procedures but do not mandate postponement for BP 160/95 1
• Her glucose of 9.1 mmol/L (164 mg/dL) falls within the acceptable perioperative target range of 100-180 mg/dL (5.6-10.0 mmol/L) 1

Glycemic Management Strategy

Her current glucose level does not require surgical delay, but medication adjustments are appropriate:

• The perioperative blood glucose target is 100-180 mg/dL (5.6-10.0 mmol/L) within 4 hours of surgery, which her current level of 164 mg/dL already meets 1
• The A1C target for elective surgeries should be <8% whenever possible, but we lack her A1C value 1, 2
• If her A1C is ≥8%, some institutions would refer to endocrinology for optimization, but this represents institutional preference rather than absolute contraindication to proceeding 2

Specific perioperative diabetes medication adjustments:

• Hold metformin on the day of surgery 1
• Discontinue SGLT2 inhibitors 3-4 days before surgery to prevent euglycemic diabetic ketoacidosis 1
• Hold other oral glucose-lowering agents the morning of surgery 1
• Give 75-80% of long-acting insulin dose or half of NPH dose based on her regimen 1
• Monitor blood glucose every 2-4 hours while NPO and dose with short- or rapid-acting insulin as needed 1
• Use basal-bolus insulin coverage postoperatively rather than correction-only insulin, as this improves outcomes and reduces perioperative complications 1

Hypertension Management Strategy

Her BP of 160/95 mmHg requires optimization but not surgical cancellation:

• The ACC/AHA recommends BP control to <130/80 mmHg before major elective procedures when reasonable 1
• Patients with controlled hypertension respond similarly to normotensive patients during anesthesia, whereas poorly controlled hypertension causes greater BP lability 1
• Continue her current antihypertensive medications through the morning of surgery with a sip of water, with specific considerations:
  • ACE inhibitors/ARBs: Recent evidence suggests holding these 24 hours before surgery reduces intraoperative hypotension and composite outcomes (death, stroke, myocardial injury), though this remains somewhat controversial 1
  • Beta blockers and clonidine: Must continue to avoid rebound hypertension 1
  • Other antihypertensives: Generally continue 1

Practical Algorithm for This Patient

Step 1: Optimize medications now (1-2 weeks before surgery if time permits):

• Adjust antihypertensive regimen to target BP <130/80 mmHg 1
• Ensure diabetes medications are optimized for perioperative period 1
• Obtain A1C if not done in past 3 months 2

Step 2: Day of surgery medication management:

• Hold metformin 1
• Hold SGLT2 inhibitors (should have been stopped 3-4 days prior) 1
• Hold other oral diabetes medications 1
• Give reduced dose of basal insulin (75-80% of usual or 50% of NPH) 1
• Consider holding ACE inhibitor/ARB 24 hours prior 1
• Continue beta blockers and clonidine 1

Step 3: Perioperative monitoring:

• Check blood glucose every 2-4 hours while NPO 1
• Maintain glucose 100-180 mg/dL with short/rapid-acting insulin 1
• Monitor BP closely during induction and perioperatively 1

Step 4: Postoperative management:

• Implement basal-bolus insulin regimen rather than sliding scale alone 1
• Resume home medications when tolerating oral intake 1

Critical Pitfalls to Avoid

• Do not use correction-only (sliding scale) insulin alone postoperatively - this approach increases complications compared to basal-bolus coverage 1
• Do not abruptly stop beta blockers or clonidine - this causes rebound hypertension 1
• Do not forget to hold SGLT2 inhibitors 3-4 days before surgery - failure to do so risks euglycemic DKA 1
• Do not target perioperative glucose <100 mg/dL - stricter targets increase hypoglycemia without improving outcomes 1
• Do not automatically cancel surgery for BP 160/95 - this level does not mandate postponement and delay may not improve long-term outcomes 1