What are the anesthesia considerations for a female patient with diabetes (Diabetes Mellitus), hypertension, hyperlipidemia, and fatty liver, who is taking colchicine (Colchicine), glipizide (Glipizide), Zetia (Ezetimibe), Lunesta (Eszopiclone), hydrocodone-acetaminophen (Hydrocodone-Acetaminophen), and metoprolol (Metoprolol), and has elevated HbA1c, liver enzymes, and lipid levels, undergoing dental extraction under general anesthesia with Versed (Midazolam), propofol, and Ketamine?

Anesthesia Considerations for Dental Extraction Under General Anesthesia

This patient can safely proceed with dental extraction under general anesthesia with appropriate perioperative management of her diabetes, hypertension, and medications, though her suboptimal glycemic control (HbA1c 8.1%) and elevated liver enzymes require specific precautions.

Preoperative Glycemic Management

Target HbA1c <8% for elective procedures whenever possible, though this patient's HbA1c of 8.1% is marginally acceptable and should not delay necessary dental care. 1

• Hold glipizide on the morning of surgery to prevent intraoperative hypoglycemia, as sulfonylureas carry significant hypoglycemia risk during fasting periods 1, 2
• Monitor blood glucose every 2-4 hours while NPO, targeting 100-180 mg/dL (5.6-10.0 mmol/L) 1, 2
• If blood glucose exceeds 180 mg/dL preoperatively, administer corrective rapid-acting insulin 1
• If blood glucose exceeds 250 mg/dL on the day of procedure, consider prophylactic antibiotics given the emergency nature of dental infection 1

Cardiovascular Risk Assessment

Diabetic patients have increased risk of perioperative hemodynamic instability due to cardiac autonomic neuropathy (CAN), which interacts unpredictably with anesthetic agents. 3

• Assess for orthostatic hypotension: measure blood pressure after 10 minutes supine, then at 1,2, and 3 minutes after standing. A drop of ≥20 mmHg systolic (or ≥30 mmHg if hypertensive) or ≥10 mmHg diastolic indicates serious sympathetic dysfunction 3
• Continue metoprolol through the morning of surgery - antihypertensive medications should be maintained until time of surgery and reinstated as soon as possible postoperatively 3
• Blood pressure should be monitored closely during general anesthesia as diabetic patients with hypertension experience wider BP fluctuations during induction and intubation 3
• Expect potential need for vasopressor support, as perioperative vasopressor requirements correlate with degree of dysautonomia in diabetic patients 3

Hepatic Considerations

The patient's elevated transaminases (ALT 72, AST 54) and fatty liver require caution with hepatically metabolized anesthetic agents, though these levels do not contraindicate general anesthesia.

• Propofol is acceptable despite fatty liver, as hepatic dysfunction becomes clinically significant only with severe cirrhosis 3
• Limit or avoid hydrocodone-acetaminophen perioperatively - the acetaminophen component poses hepatotoxicity risk in patients with baseline elevated liver enzymes, and opioids should be minimized regardless 4
• Midazolam and ketamine are metabolized hepatically but are safe at standard anesthetic doses in patients with fatty liver without cirrhosis 4

Medication Management on Day of Surgery

Hold glipizide on the morning of surgery 1, 2

Continue metoprolol succinate ER - beta-blockers should be maintained perioperatively, particularly in diabetic patients who may benefit from hemodynamic stability 3

Continue Zetia (ezetimibe) - lipid medications do not require perioperative adjustment 5

Hold Lunesta (eszopiclone) - avoid additional sedative-hypnotics on the day of general anesthesia due to additive CNS depression with midazolam 4

Hold colchicine on day of surgery - while not specifically contraindicated, minimizing non-essential medications reduces drug interaction complexity

Avoid hydrocodone-acetaminophen perioperatively - use alternative analgesics without acetaminophen given elevated baseline liver enzymes 1

Anesthetic Drug Interactions and Precautions

The combination of midazolam, propofol, and ketamine is acceptable but requires careful titration and monitoring due to multiple comorbidities.

• Midazolam doses should be reduced in patients with multiple comorbidities and those on CNS depressants. The FDA label specifically warns that "intravenous doses of midazolam should be decreased for elderly and for debilitated patients" and emphasizes careful titration 4
• Concomitant use of benzodiazepines (midazolam) with opioids increases respiratory depression risk through actions at different CNS receptor sites. If any opioid is used perioperatively, monitor closely for respiratory depression 4
• Propofol and ketamine do not have specific contraindications in diabetic patients with controlled hypertension 3
• Ensure adequate personnel and equipment for airway management - practitioners must have skills to manage foreseeable adverse effects, particularly airway complications 4

Aspiration Risk Assessment

Standard NPO guidelines apply: clear liquids until 2 hours before anesthesia, light meals until 6 hours before 2

• This patient is NOT on GLP-1 receptor agonists, so extended fasting is unnecessary 3
• Diabetic patients without documented gastroparesis have normal gastric emptying and can follow standard fasting protocols 2
• Consider rapid-sequence intubation technique given general anesthesia in dental office setting where aspiration risk management is critical 3

Intraoperative Glucose Monitoring

Monitor blood glucose every 1-2 hours during the procedure, targeting 100-180 mg/dL 1, 6

• Administer corrective subcutaneous rapid-acting insulin if blood glucose exceeds 180 mg/dL 1
• Have IV dextrose available if blood glucose drops below 100 mg/dL 1

Postoperative Management

Resume oral feeding as soon as patient is awake and free of nausea 1, 6, 2

• Continue blood glucose monitoring every 2-4 hours until stable and eating 1, 2
• Resume glipizide when blood glucose is 90-180 mg/dL AND patient is tolerating oral intake 1, 2
• Resume metoprolol as soon as patient can take oral medications 3
• If blood glucose exceeds 300 mg/dL postoperatively, check for ketosis and consider hospitalization for IV insulin 1, 6

Critical Pitfalls to Avoid

Do not continue glipizide on the morning of surgery - sulfonylureas cause hypoglycemia during fasting 1, 2

Do not use acetaminophen-containing analgesics given elevated baseline liver enzymes - choose NSAIDs or opioid-free alternatives 1

Do not abruptly discontinue metoprolol - maintain beta-blockade throughout perioperative period 3

Do not assume normal hemodynamic responses - diabetic patients with autonomic neuropathy may have unpredictable responses to anesthetic agents and require closer monitoring 3

Do not delay procedure for HbA1c of 8.1% - while suboptimal, this level is acceptable for necessary dental care with appropriate glucose monitoring 1