Prevention of Complications in Women with Diabetes Undergoing Surgery
4/1/2018 - Tara E. Kelly, MD
Mentor: Julie DeCesare, MD
Editor: Christine Isaacs, MD
Diabetes mellitus (DM) is a common and increasingly prevalent chronic medical condition with an incidence of one in 11 persons worldwide. Approximately half of these cases are undiagnosed.
Routine screening for diabetes is not recommended at time of preoperative evaluation. However, it is appropriate to test women who meet American Diabetes Association (ADA) or U.S. Preventative Screening Task Force (USPSTF) screening criteria and who have not been recently tested. If DM is diagnosed preoperatively, the patient should be evaluated for the presence of diabetes-related complications.
In diabetic patients, surgical stress leads to worsening insulin resistance, decreased peripheral glucose utilization, impaired insulin secretion, and increased protein catabolism causing hyperglycemia and possible ketosis in Type 1 diabetic patients. General anesthesia is associated with a larger stress response compared with regional anesthesia. The extent of this response is also dependent on the complexity and duration of the surgery as well as postoperative factors. A preoperative risk assessment should be performed for patients at high risk for ischemic heart disease and with autonomic neuropathy or renal failure.
Glycemic control is critical, and is covered in a separate Pearl (see Glycemic Control in Women with Diabetes Undergoing Surgery).
Multiple strategies exist to prevent cardiovascular complications in a patient with diabetes. Patients with indications for chronic use of beta-blockers (hypertension, atrial fibrillation, angina, heart failure, or a history of myocardial infarction) should be continued on them preoperatively. Diabetic patients with chronic hypertension should have their blood pressure optimized. Since diabetes confers an increased risk of cardiovascular events, lipid-lowering therapy should be considered preoperatively.
Patients with diabetic gastroparesis should receive a prokinetic agent prior to the administration of general anesthesia to decrease aspiration risk. Attempts should be made to minimize opioid use to prevent additional decreased motility.
It is important to avoid hypotension in patients with diabetic kidney disease (formerly referred to as nephropathy). Surgery results in large fluid shifts, which can lead to ischemic renal injury, and which is more likely in the setting of pre-existing diabetic kidney disease. Non-steroidal anti-inflammatory drugs (NSAIDS) should be used cautiously.
Patients with diabetic autonomic kidney disease are at increased risk of peripheral neuropathy. Surgical positioning and cushioning should be optimized.
Postoperatively, diabetic patients have an increased risk of infections and wound complications. Prevention strategies include attention to aseptic technique and adherence to proper antibiotic prophylaxis with appropriate dose adjustment for weight. Because patients with diabetes are at risk for poor wound healing, surgeons should optimize intraoperative temperature control with the use of blankets or forced-air warming systems. Hypothermia can lead to peripheral insulin resistance, hyperglycemia, decreased wound healing, and infection.
Gala RB. Preoperative Considerations. Williams Gynecology. 2nd ed. New York, NY: McGraw-Hill Education LLC. 2016.
American Diabetes Association. Standards of Medical Care in Diabetes- 2018. Diabetes Care 2018 Jan; 41(Supplement 1): S144-S151. Available at: http://care.diabetesjournals.org/content/41/Supplement_1/S144. Accessed 1/5/18.
Companion Pearl: Glycemic Control in Diabetic Patients Undergoing Gynecologic Surgery
Initial Approval: January 2, 2018.
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