What is the best course of action for an elderly female patient with a history of Hypertension (HTN) and Diabetes Mellitus (DM), presenting with uncontrolled blood pressure and elevated glucose levels, who is scheduled for elective surgery?

Adjust HTN and DM Medications - Do Not Postpone Surgery

Based on current evidence-based guidelines, you should proceed with surgery after optimizing her blood pressure and glucose control in the immediate preoperative period, rather than postponing for one month. 1, 2

Blood Pressure Management

Her BP of 160/95 mmHg falls within the acceptable range to proceed with elective surgery. 1

• The American Heart Association and American College of Cardiology recommend proceeding with surgery for patients with BP <160/100 mmHg 1
• For BP between 160-179/100-109 mmHg (which includes this patient at 160/95), guidelines recommend proceeding with surgery while informing the primary care physician to optimize the antihypertensive regimen 1
• Surgery should only be deferred if BP ≥180/110 mmHg 3, 1

Key action: Continue her current antihypertensive medications throughout the perioperative period, as most should not be stopped 1. The exception is ACE inhibitors/ARBs, which should be held on the day of surgery but restarted postoperatively 1.

Glucose Management

Her glucose of 9.1 mmol/L (164 mg/dL) is within acceptable perioperative targets and does not require surgical postponement. 3

The critical threshold for postponing elective surgery is HbA1c >8%, not a single glucose reading 2. Her current glucose falls within the recommended perioperative target range of 5.6-10.0 mmol/L (100-180 mg/dL) 3.

Essential perioperative glucose management steps:

• Check HbA1c if not recently done - this is the key determinant for surgical timing 2. If HbA1c >8%, then consider postponement and referral to endocrinology 2
• Hold metformin on the day of surgery 3
• Discontinue SGLT2 inhibitors 3-4 days before surgery 3, 2
• Hold other oral glucose-lowering agents the morning of surgery 3
• Give 75-80% of long-acting insulin dose or half of NPH dose 3
• Monitor blood glucose every 2-4 hours while NPO 3
• Use basal-bolus insulin coverage perioperatively rather than correction-only insulin, as this reduces complications 3

Why Not Postpone for One Month?

Postponement is not indicated based on these values and would cause unnecessary delay without clinical benefit:

• Her BP does not meet the threshold for mandatory postponement (≥180/110 mmHg) 3, 1
• A single glucose reading of 9.1 mmol/L does not indicate poor control requiring delay 3
• Surgical postponement carries significant psychological, social, and financial implications for patients without clear benefit when values are within acceptable ranges 3

The only scenario requiring postponement would be if her HbA1c is >8%, in which case referral to diabetology/endocrinology for treatment intensification before elective surgery would be appropriate 2.

Common Pitfalls to Avoid

• Do not use correction-only insulin perioperatively - basal-bolus regimens significantly reduce complications 3
• Do not forget to discontinue SGLT2 inhibitors 3-4 days preoperatively - this prevents euglycemic diabetic ketoacidosis 3, 2
• Do not aim for overly strict glucose targets - perioperative goals tighter than 4.4-10.0 mmol/L increase hypoglycemia without improving outcomes 3
• Do not stop all antihypertensives - most should be continued to avoid rebound hypertension 1