Perioperative Management in Patients with Diabetes Mellitus: A Comprehensive Review

Ririn Widya Ningrum, Eva Niamuzisilawati

Abstract

Introduction: The global prevalence of Diabetes Mellitus (DM) is rising, proportionately increasing the number of diabetic patients requiring surgical interventions. Surgery induces a profound metabolic stress response that disrupts glucose homeostasis, leading to hyperglycemia, increased insulin resistance, and a higher propensity for perioperative complications such as surgical site infections (SSI), acute kidney injury, cardiovascular events, and increased mortality. This review highlights the critical purpose of standardizing perioperative management in diabetic patients to optimize metabolic control and improve surgical outcomes.

Methods: A comprehensive narrative literature review was conducted evaluating guidelines and evidence from prominent medical societies, including the American Diabetes Association (ADA), the Indonesian Society of Endocrinology (PERKENI), and recent clinical trials. The evaluation encompasses pre-operative risk assessment, intra-operative glycemic targets, specific management of various anti-diabetic agents, and post-operative care transitions.

Results: Pre-operative management mandates a thorough risk assessment and achieving a target HbA1c of less than 8% for elective surgeries, alongside careful cessation or adjustment of oral anti-diabetic drugs, particularly emphasizing the withholding of SGLT2 inhibitors and GLP-1 receptor agonists due to specific perioperative risks. Intra-operatively, blood glucose should be maintained between 140–180 mg/dL. Tight glycemic control (80–110 mg/dL) is heavily discouraged due to the risk of undetected severe hypoglycemia. Continuous intravenous insulin infusion is recommended for major or prolonged surgeries. Post-operatively, a structured transition from intravenous to subcutaneous basal-bolus insulin is crucial once the patient achieves hemodynamic stability and resumes oral intake, avoiding the outdated sliding-scale insulin regimens.

Conclusions: Perioperative management of DM demands a highly coordinated, multidisciplinary approach involving surgeons, anesthesiologists, and endocrinologists. The implementation of individualized, evidence-based glycemic protocols across the entire perioperative continuum significantly mitigates morbidity, prevents metabolic emergencies, and improves overall patient survival and recovery.

Keywords: Diabetes Mellitus; Perioperative Care; Glycemic Control; Insulin Therapy; Surgical Outcomes; Surgical Stress.

Keywords

Perioperative Management; Diabetes Mellitus

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References

Aman, A.M. Tata laksana perioperatif pada pasien diabetes melitus. In Buku Ajar Ilmu Penyakit Dalam, 7th ed.; Alwi, I., Satyawan, S., Eds.; Perhimpunan Dokter Spesialis Penyakit Dalam Indonesia (PB PAPDI): Jakarta, Indonesia, 2024; Volume 3, pp. 336–338.

Frisch, A.; Chandra, P.; Smiley, D.; Peng, L.; Rizzo, M.; Gatcliffe, C.; Hudson, M.; Mendoza, J.; Johnson, J.; Lin, E.; et al. Prevalence and clinical outcome of hyperglycemia in the perioperative period in noncardiac surgery. Diabetes Care 2010, 33, 1783–1788.

Desborough, J.P. The stress response to trauma and surgery. Br. J. Anaesth. 2000, 85, 109–117.

Finnerty, C.C.; Mabvuure, N.T.; Ali, A.; Kozar, R.A.; Herndon, D.N. The surgically induced stress response. JPEN J. Parenter. Enteral Nutr. 2013, 37, 21S–29S.

Thorell, A.; Nygren, J.; Ljungqvist, O. Insulin resistance: A marker of surgical stress. Curr. Opin. Clin. Nutr. Metab. Care 1999, 2, 69–78.

Clement, S.; Braithwaite, S.S.; Magee, M.F.; Ahmann, A.; Smith, E.P.; Schafer, R.G.; Hirsch, I.B. Management of diabetes and hyperglycemia in hospitals. Diabetes Care 2004, 27, 553–591.

He, C.; Zhou, F.; Zhou, F.; Wang, J.; Huang, W. Impact of type 2 diabetes on surgical site infections and prognosis post orthopaedic surgery: a systematic review and meta-analysis. Int. Wound J. 2024, 21, e14422.

Calderwood, M.S.; Anderson, D.J.; Bratzler, D.W.; Dellinger, E.P.; Garcia Houchins, S.; Maragakis, L.L.; et al. Strategies to prevent surgical site infections in acute-care hospitals: 2022 update. Infect. Control Hosp. Epidemiol. 2023, 44, 695–720.

The NICE-SUGAR Study Investigators. Intensive versus conventional glucose control in critically ill patients. N. Engl. J. Med. 2009, 360, 1283–1297.

Moghissi, E.S.; Korytkowski, M.T.; DiNardo, M.; Einhorn, D.; Hellman, R.; Hirsch, I.B.; Inzucchi, S.E.; Ismail-Beigi, F.; Kirkman, M.S.; Umpierrez, G.E. American Association of Clinical Endocrinologists and American Diabetes Association consensus statement on inpatient glycemic control. Diabetes Care 2009, 32, 1119–1131.

Vinik, A.I.; Ziegler, D. Diabetic cardiovascular autonomic neuropathy. Circulation 2007, 115, 387–397.

American Diabetes Association. 16. Diabetes Care in the Hospital: Standards of Medical Care in Diabetes—2023. Diabetes Care 2023, 46 (Suppl. 1), S267–S278.

Perkeni. Terapi Insulin pada Pasien Perioperatif. In Pedoman Praktis Terapi Insulin pada Pasien Diabetes Melitus 2021; PB Perkeni: Jakarta, Indonesia, 2021; pp. 40–41.

Underwood, P.; Askari, R.; Hurwitz, S.; Chamarthi, B.; Garg, R. Preoperative A1C and clinical outcomes in patients with diabetes undergoing major noncardiac surgical procedures. Diabetes Care 2014, 37, 611–616.

Centre for Perioperative Care. Guideline for perioperative care for people with diabetes mellitus undergoing elective and emergency surgery; Medical Academy: London, UK, 2021.

Nazer, R.I.; Alnajashi, K.H.; Alhazmi, H.; Aljehani, Y.M.; Alharbi, M.A. The impact of withholding metformin in the perioperative period: A systematic review. J. Anaesthesiol. Clin. Pharmacol. 2021, 37, 523–529.

Thiruvenkatarajan, V.; Meyer, E.J.; Nanjappa, N.; Van Wijk, R.M.; Jesudason, D. Perioperative diabetic ketoacidosis associated with sodium-glucose co-transporter-2 inhibitors: A systematic review. Br. J. Anaesth. 2019, 123, 27–36.

Joshi, G.P.; Abdelmalak, B.B.; Weigel, W.A.; Harbell, M.W.; Cohen, C.E.; et al. American Society of Anesthesiologists Consensus-Based Guidance on Preoperative Management of Patients (Adults and Children) on Glucagon-Like Peptide-1 (GLP-1) Receptor Agonists. American Society of Anesthesiologists, 2023.

Turchin, A.; Zhang, H.; Shubina, M. Preoperative DPP-4 inhibitor use and incidence of perioperative complications in patients with type 2 diabetes. J. Clin. Endocrinol. Metab. 2016, 101, 4402–4409.

Australian Diabetes Society. Peri-operative diabetes management guidelines; Australian Diabetes Society: Sydney, Australia, 2012.

Joshi, G.P.; Chung, F.; Vann, M.A.; Ahmad, S.; Gan, T.J.; Goulson, D.T.; et al. Society for Ambulatory Anesthesia consensus statement on perioperative blood glucose management in diabetic patients undergoing ambulatory surgery. Anesth. Analg. 2010, 111, 1378–1387.

Partridge, H.; Perkins, B.; Mathieu, S.; Nicholls, A.; Adeniji, K. Clinical recommendations in the management of the patient with type 1 diabetes on insulin pump therapy in the perioperative period: a primer for the anaesthetist. Br. J. Anaesth. 2016, 116, 18–26.

Lazar, H.L.; McDonnell, M.; Chipkin, S.R.; Furnary, A.P.; Engelman, R.M.; Sadhu, A.R.; et al. The Society of Thoracic Surgeons practice guideline series: Blood glucose management during adult cardiac surgery. Ann. Thorac. Surg. 2009, 87, 663–669.

Umpierrez, G.E.; Smiley, D.; Jacobs, S.; Peng, L.; Temponi, A.; Mulligan, P.; et al. Randomized study of basal-bolus insulin therapy in the inpatient management of patients with type 2 diabetes undergoing general surgery (RABBIT 2 Surgery). Diabetes Care 2011, 34, 256–261.

Alberti, K.G.; Thomas, D.J. The management of diabetes during surgery. Br. J. Anaesth. 1979, 51, 693–710.

Evans, K.; Rush, R. The perioperative management of the diabetic patient. Ann. R. Coll. Surg. Engl. 2015, 97, 336–340.

Thomas, D.J.; Alberti, K.G. Hyperglycaemic effects of Hartmann's solution during surgery in patients with maturity onset diabetes. Br. J. Anaesth. 1978, 50, 185–188.

Kotagal, M.; Symons, R.G.; Hirsch, I.B.; Umpierrez, G.E.; Perez, A.; Rubin, E.E.; et al. Perioperative hyperglycemia and risk of adverse events among patients with and without diabetes. Ann. Surg. 2015, 261, 97–103.

Umpierrez, G.E.; Hellman, R.; Korytkowski, M.T.; Kosiborod, M.; Maynard, G.A.; Montori, V.M.; et al. Management of hyperglycemia in hospitalized patients in non-critical care setting: An endocrine society clinical practice guideline. J. Clin. Endocrinol. Metab. 2012, 97, 16–38.

Schmeltz, L.R.; DeSantis, A.S.; Thiyagarajan, V.; Schmidt, K.; O'Shea-Mahler, E.; Johnson, D.; et al. Reduction of surgical mortality and morbidity in diabetic patients undergoing cardiac surgery with a combined intravenous and subcutaneous insulin glucose management strategy. Diabetes Care 2007, 30, 823–828.

Umpierrez, G.E.; Smiley, D.; Zisman, A.; Prieto, L.M.; Palacio, A.; Cotes, M.; et al. Randomized study of basal-bolus insulin therapy in the inpatient management of patients with type 2 diabetes (RABBIT 2 trial). Diabetes Care 2007, 30, 2181–2186.

Ljungqvist, O.; Scott, M.; Fearon, K.C. Enhanced Recovery After Surgery: A Review. JAMA Surg. 2017, 152, 292–298.

Gustafsson, U.O.; Nygren, J.; Thorell, A.; Soop, M.; Hellström, P.M.; Ljungqvist, O.; et al. Pre-operative carbohydrate loading may be used in type 2 diabetes patients. Acta Anaesthesiol. Scand. 2008, 52, 946–951.

DOI: https://doi.org/10.20961/tscm.v1i1.117086

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