Evaluation and perioperative management of patients with diabetes mellitus. A challenge for the anesthesiologist

Pontes, João Paulo Jordão; Mendes, Florentino Fernandes; Vasconcelos, Mateus Meira; Batista, Nubia Rodrigues

doi:10.1016/j.bjane.2017.06.002

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Review Article • Rev. Bras. Anestesiol. 68 (1) • Jan-Feb 2018 • https://doi.org/10.1016/j.bjane.2017.06.002 copy

Evaluation and perioperative management of patients with diabetes mellitus. A challenge for the anesthesiologist^☆ ☆ Center: Complexo Hospitalar Santa Genoveva, Uberlândia, MG, Brazil.

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Diabetes mellitus (DM) is characterized by alteration in carbohydrate metabolism, leading to hyperglycemia and increased perioperative morbidity and mortality. It evolves with diverse and progressive physiological changes, and the anesthetic management requires attention regarding this disease interference in multiple organ systems and their respective complications. Patient's history, physical examination, and complementary exams are important in the preoperative management, particularly glycosylated hemoglobin (HbA1c), which has a strong predictive value for complications associated with diabetes. The goal of surgical planning is to reduce the fasting time and maintain the patient's routine. Patients with Type 1 DM must receive insulin (even during the preoperative fast) to meet the basal physiological demands and avoid ketoacidosis. Whereas patients with Type 2 DM treated with multiple injectable and/or oral drugs are susceptible to develop a hyperglycemic hyperosmolar state (HHS). Therefore, the management of hypoglycemic agents and different types of insulin is fundamental, as well as determining the surgical schedule and, consequently, the number of lost meals for dose adjustment and drug suspension. Current evidence suggests the safe target to maintain glycemic control in surgical patients, but does not conclude whether it should be obtained with either moderate or severe glycemic control.

KEYWORDS
Diabetes mellitus; Anesthesia; Perioperative care; Hypoglycemic agents; Insulin; Glycosylated hemoglobin

HbA1c (%)	Plasma mean glycemia
	mg.dL^-1	mmol.L^-1
6	126	7.0
7	154	8.6
8	186	10.2
8.5	200	11.0
9	212	11.8
10	240	13.4
11	269	14.9
12	298	16.5

Class (trade name)	Previous day	Day of surgery
		Morning surgery	Afternoon surgery
Biguanides		Regular use, unless contraindicated^a a Use of radiological contrast, GFR < 60 mL.min-1, elevated creatinine or significant risk of ARF.2 Adapted from Refs. 2,8,17.
Metformin (Glifage^®)

Sulphonylureas	Regular use	Omit the dose regardless of the time
Gliclazide (Diamicron^®)
Glibenclamide (Daonil^®)
Glimepiride (Amaryl^®)
Glipizide (Glucotrol^®)

Glinides	Regular use	Omit the morning dose	Take the morning dose (pre-meal) if the patient had breakfast
Nateglinide (Starlix^®)
Repaglinide (Prandin^®)

Alpha-glucosidase inhibitors
Acarbose (Glucobay^®)

Glitazones	Regular use	Regular use (attention to patients at risk for cardiac congestion)
Rosiglitazone (Avandia^®)
Pioglitazone (Actos^®)

DPP-4 inhibitors	Regular use	Regular use²2 Barker P, Creasey PE, Dhatariya K, et al. Peri-operative management of the surgical patient with diabetes 2015: Association of Anaesthetists of Great Britain and Ireland. Anaesthesia. 2015;70:1427-40. or omit the dose on the day of surgery (potential delay of gastric emptying)⁸8 Soldevila B, Lucas AM, Zavala R, et al. Perioperative management of the diabetic patient. In: Stuart-Smith K, editor. Perioperative medicine - current controversies. Switzerland: Springer; 2016. p. 165-92.
Sitagliptin (Januvia^®)
Vildagliptin (Galvus^®)
Saxagliptin (Onglyza^®)
Alogliptin (Nesina^®)
Linagliptin (Trayenta^®)

GLP1 analogs
Exenatide (Byetta^® Bydureon^®)
Liraglutide (Victoza^®)

SGLT-2 inhibitors	Regular use	Omit dose on the day of surgery. Attention for concomitant use of diuretics.
Dapaglifozina (Forxiga^®)
Canaglifozina (Invokana^®)
Empaglifozina (Jardiance^®)

Drug class: generic (trade name)	Onset	Peak effect	Duration
Rapid acting analogs
Lispro (Humalog^®)	5-15 min	30-90 min	4-6 h
Aspart (Novolog^® Novorapid^®)	5-15 min	30-90 min	4-6 h
Glulisin (Apidra^®)	5-15 min	30-90 min	4-6 h

Short action
Regular (Novolin R^® Humulin^®)	30-60 min	2-4 h	6-8 h

Intermediate action
NPH (Novolin N^® Humulin N^®)	2-4 h	4-10 h	10-16 h
Insulin zincica (Lente^®)	2-4 h	4-10 h	12-20 h
Extended zinc insulin (Ultralente^®)	6-10 h	10-16 h	18-24 h

Long/basal action
Glargine (Lantus^®)	2-4 h	None	20-24 h
Detemir (Levemir^®)	2-4 h	None	20-24 h
Degludec (Tresiba^®)	2-4 h	None	≥42 h

Pre-mixed (NPH + regular)
70% NPH/30% regular (Novolin 70/30^®, Humulin 70/30^®)	30-90 min	Dual	10-16 h
50% NPH/50% regular (Humulin 50/50^®)	30-90 min	Dual	10-16 h

Pre-mixed (intermediate-acting + short-acting analogs)
70% Aspart Protamine suspension/30% Aspart (Novolog mix 70/30^®)	5-15 min	Dual	10-16 h
75% Lispro Protamine suspension/25% Lispro (Humalog mix 75/25^®)	5-15 min	Dual	10-16 h
50% Lispro Protamine suspension/50% Lispro (Humalog mix 50/50^®)	5-15 min	Dual	10-12 h

Type of insulin	Previous day	Day of surgery
		Morning surgery	Afternoon surgery
Continuous subcutaneous insulin infusion (pump)	Maintain basal infusion or reduce 20-30% of baseline if history of frequent hypoglycemia

Long-acting or basal insulin (glargine, detemir)	Morning application: maintain dose Night application: maintain dose or reduce 20-30%^b b History of hypoglycemia during dawn/morning. Adapted from Refs. 2,17,61,64.	Morning application^a a On the day of surgery, the morning insulin should be given upon arrival at the health center. : Maintain dose or reduce 20-30% if history of frequent hypoglycemia. Check blood glucose at admission

Intermediate-acting insulin (NPH)	Morning application: maintain dose Night application: maintain dose or reduce 20-30%^b b History of hypoglycemia during dawn/morning. Adapted from Refs. 2,17,61,64.	Reduce morning dose by 50%^a a On the day of surgery, the morning insulin should be given upon arrival at the health center. ; check blood glucose at admission; keep evening dose unchanged after surgery (if already fed)

Pre-mixed insulin	Maintain dose	Reduce morning dose intermediate insulin to 50%; omit the dose of fast/short-acting insulin. Check blood glucose at admission. Keep evening dose unchanged after surgery (if already fed)

Fast-acting or short-acting insulin analogs	Maintain dose	Hold dose	Hold dose

Sociedade Brasileira de Anestesiologia R. Professor Alfredo Gomes, 36, 22251-080 Botafogo RJ Brasil, Tel: +55 21 2537-8100, Fax: +55 21 2537-8188 - Campinas - SP - Brazil
E-mail: bjan@sbahq.org

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[1] * Corresponding author. E-mail:pontes_ufu@yahoo.com.br (J.P. Pontes).

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Evaluation and perioperative management of patients with diabetes mellitus. A challenge for the anesthesiologist☆ ☆ Center: Complexo Hospitalar Santa Genoveva, Uberlândia, MG, Brazil.

Abstract

Evaluation and perioperative management of patients with diabetes mellitus. A challenge for the anesthesiologist^☆ ☆ Center: Complexo Hospitalar Santa Genoveva, Uberlândia, MG, Brazil.