Perioperative anesthesia management in patients with diabetes mellitus

Diabetology · Endocrinology · Anesthesiology

Diabetes mellitus (DM) is a chronic multisystem disorder with a growing global prevalence, affecting approximately 537 million adults worldwide, with projections reaching 783 million by 2045. It is an important comorbidity in patients undergoing surgery, as metabolic disturbances, impaired wound healing, and associated cardiovascular and autonomic complications can increase perioperative risks. The physiological stress response to surgery and anaesthesia triggers the release of counter-regulatory hormones, increasing insulin resistance and causing fluctuations in blood glucose levels. These changes may contribute to perioperative hyperglycaemia, hypoglycaemia, infections, delayed wound healing, and cardiovascular complications. Therefore, effective perioperative management requires comprehensive preoperative assessment, appropriate adjustment of antidiabetic medications, regular intraoperative glucose monitoring, and individualised postoperative glycaemic control to minimise complications and promote optimal recovery.[1]Preoperative assessment and optimizationA detailed medical history should identify the duration and type of diabetes, current glycemic control, antidiabetic medications, previous hypoglycemic episodes, and history of diabetic complicationsCardiovascular risk assessment should be prioritized in patients with suspected ischemic heart disease, autonomic neuropathy, or diabetic nephropathyGlycated hemoglobin (HbA1c) should ideally be assessed within 3 months before elective surgery, with a target of less than 8% whenever clinically appropriateRenal function, electrolyte levels, hydration status, and blood glucose should be evaluated to identify metabolic abnormalities that may influence anesthetic managementPerioperative management of antidiabetic medicationsMetformin should generally be withheld on the day of surgery, while other oral glucose-lowering medications should be withheld on the morning of the procedure according to the applicable perioperative protocolSodium-glucose cotransporter-2 (SGLT2) inhibitors should be discontinued 3–4 days before scheduled surgery to reduce the risk of perioperative euglycemic diabetic ketoacidosisInsulin requirements should be individualized according to the patient's diabetes type, usual insulin regimen, fasting duration, and anticipated surgical stressBasal insulin should generally be continued with an appropriate dose adjustment, whereas prandial insulin should be withheld during fastingPatients receiving glucagon-like peptide-1 (GLP-1) receptor agonists require assessment of gastrointestinal symptoms and aspiration risk because delayed gastric emptying may influence anesthetic planning. Medication management should follow current institutional guidanceIntraoperative anesthetic considerationsBlood glucose should be maintained between 100 and 180 mg/dL during the perioperative period, with individualized targets based on clinical circumstances and hypoglycemia riskPoint-of-care blood glucose monitoring should be performed regularly, generally every 2–4 hours during fasting, with more frequent assessment when clinically indicatedContinuous glucose monitoring (CGM) should not be used as the sole method of intraoperative glucose assessmentInsulin therapy should be adjusted according to measured glucose levels, with intravenous insulin considered when clinically indicated for prolonged or complex proceduresAnesthetic management should account for autonomic neuropathy, which may cause hemodynamic instability, impaired cardiovascular responses, and delayed gastric emptyingAppropriate precautions should be taken against aspiration in patients with suspected gastroparesis or other risk factors for delayed gastric emptyingPostoperative managementBlood glucose monitoring should continue in the postanesthesia care unit (PACU) to identify persistent hyperglycemia or hypoglycemiaInsulin therapy should be adjusted according to oral intake, metabolic status, and postoperative requirementsAntidiabetic medications should be restarted when the patient is clinically stable and medication-specific safety criteria have been metPostoperative surveillance should include assessment for surgical site infections, delayed wound healing, and metabolic complicationsAdditional considerations affecting anesthetic planningClinical conditionPotential anesthetic implicationDiabetic autonomic neuropathyAltered heart rate variability and blood pressure regulation.Diabetic nephropathyAltered drug clearance and increased risk of fluid and electrolyte disturbances.Diabetic peripheral neuropathyIncreased vulnerability to positioning-related nerve injury.Diabetic gastroparesisIncreased risk of pulmonary aspiration during anesthesia.Diabetic retinopathyConsideration of existing ocular complications during perioperative care.ConclusionPerioperative anaesthetic management of patients with diabetes mellitus requires an individualised, multidisciplinary approach focused on maintaining glycaemic stability and minimising complications. A thorough understanding of antidiabetic medications, their mechanisms of action, and appropriate perioperative adjustments is essential for safe anaesthetic care. Careful preoperative assessment of associated diabetic complications, regular blood glucose monitoring, and coordinated postoperative glycaemic management are equally important. These measures help reduce metabolic and perioperative complications, promote recovery, and improve overall surgical outcomes.[2]Reference(s):1. Crowley K, Scanaill PÓ, Hermanides J, Buggy DJ. Current practice in the perioperative management of patients with diabetes mellitus: a narrative review. Br J Anaesth. 2023;131(2):242-252. doi:10.1016/j.bja.2023.02.039. https://pmc.ncbi.nlm.nih.gov/articles/PMC10375498/2. Cornelius BW. Patients With Type 2 Diabetes: Anesthetic Management in the Ambulatory Setting: Part 2: Pharmacology and Guidelines for Perioperative Management. Anesth Prog. 2017;64(1):39-44. doi:10.2344/anpr-64-01-02. https://pmc.ncbi.nlm.nih.gov/articles/PMC5278535/