Anaesthetic Considerations in Diabetic Patients
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Anaesthetic Considerations in Diabetic Patients
(>180 mg/dL)
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Anaesthetic Considerations in Diabetic Patients
🔑 Key Statistics & Risks
- Prevalence: Diabetic patients represent 15–20% of surgical populations globally
- Cardiovascular risk: 2–3× higher risk of cardiovascular complications
- Infection risk: Glucose >180 mg/dL significantly increases surgical site infection risk
- Renal complications: Higher incidence of acute kidney injury (AKI) and prolonged hospital stays
- Primary goal: Avoid extremes—prevent both hypoglycaemia (<70 and="" dl="" mg="" strong="">hyperglycaemia
🩺 Preoperative Assessment Essentials
Diabetes History
- Type and duration: Duration >10 years = higher risk
- HbA1c target: <8 .5="" consider="" elective="" for="" if="" postponing="" surgery="">9% in high-risk procedures
- Hypoglycaemia awareness: Especially nocturnal episodes
- Full medication review: Including SGLT2 inhibitors, GLP-1 agonists
Critical Complication Screening
- Cardiovascular: Silent myocardial ischaemia in 20–40% due to autonomic neuropathy; assess angina equivalents (dyspnoea, fatigue)
- Autonomic neuropathy: Screen for orthostatic dizziness, gastroparesis, resting tachycardia → causes haemodynamic instability, blunted HR response, aspiration risk, exaggerated hypotension with regional anaesthesia
- Renal: Check eGFR and urine albumin:creatinine ratio; preoperative renal failure is strongest predictor of cardiac complications
- Airway/GI: Gastroparesis → delayed gastric emptying (consider RSI); stiff joint syndrome may complicate intubation
💊 Perioperative Medication Management
| Medication | Recommendation | Rationale |
|---|---|---|
| SGLT2 inhibitors | Withhold ≥24h (T2DM) to 48h (T1DM) pre-op | Risk of euglycaemic DKA during fasting/stress |
| GLP-1 agonists | Weekly: withhold 1 week; Daily: withhold 24–48h | Delayed gastric emptying → aspiration risk |
| Metformin | Withhold morning of surgery | Lactic acidosis risk with hypoperfusion/contrast |
| Sulfonylureas | Withhold morning dose | Prolonged hypoglycaemia risk under anaesthesia |
| Long-acting insulin | Continue at 70–80% usual dose | Maintains basal coverage while reducing hypoglycaemia risk |
| Short-acting insulin | Withhold; replace with IV protocol | Unpredictable absorption during fasting |
📊 Glycaemic Targets & Monitoring
- Target range: 100–180 mg/dL (5.6–10.0 mmol/L) throughout perioperative period
- Acceptable range: 80–200 mg/dL for most procedures
- Tighter control: 110–150 mg/dL may benefit cardiac surgery patients
- Monitoring frequency: Hourly (more frequently if unstable); critical in autonomic neuropathy where hypoglycaemia warning signs are absent
- Fluids: Avoid dextrose-containing fluids unless treating hypoglycaemia
- Crystalloids: Use balanced crystalloids (e.g., Plasmalyte) over normal saline to prevent hyperchloraemic acidosis
- Electrolytes: Monitor potassium closely (shifts with insulin administration)
- Steroids: Low-dose dexamethasone (4 mg) acceptable for PONV prophylaxis
⚠️ Intraoperative Considerations
- Schedule diabetic patients early to minimize fasting duration
- Induction agents may cause profound hypotension in autonomic neuropathy
- Consider BIS monitoring to avoid excessive anaesthetic dosing
- For regional anaesthesia: anticipate exaggerated hypotension; have vasopressors ready; peripheral neuropathy may mask compartment syndrome
🔄 Postoperative Transition
- Continue hourly glucose monitoring until regular oral intake
- Transition to subcutaneous insulin: give first SC dose 1–2 hours BEFORE stopping IV insulin to prevent rebound hyperglycaemia
- Resume oral agents only after confirming stable renal function and adequate oral intake
- Early mobilisation reduces insulin resistance and infection risk
🏥 The 5 Pillars of Safe Anaesthesia in Diabetics
- Comprehensive preoperative assessment: Autonomic neuropathy, CV disease, renal function—not just HbA1c
- Strategic medication management: Especially newer agents to prevent euDKA/aspiration
- Targeted glycaemic control: 100–180 mg/dL; avoid extremes
- Vigilant intraoperative monitoring: Hourly glucose, fluid/electrolytes, haemodynamic lability
- Structured transitions: Safe IV-to-SC insulin handover; delayed oral agent restart
❓ Critical FAQs
HbA1c 9.2% – should I postpone surgery?
Not automatic postponement—proceed with urgent surgery using intensive glucose control; consider 4–6 weeks optimisation for elective high-risk surgery if >9%
Emergency surgery on SGLT2i – what's the risk?
Check venous blood gas for ketones immediately—even with normal glucose; treat euDKA if present before proceeding
Is tight control (80–110 mg/dL) better?
No—NICE-SUGAR trial showed increased mortality from hypoglycaemia; 140–180 mg/dL is current safe target
Quick autonomic neuropathy screen?
Ask: (1) orthostatic dizziness? (2) postprandial nausea/fullness? (3) resting tachycardia? Positive responses = haemodynamic caution needed
📚 References
- NICE-SUGAR Trial (2009) - New England Journal of Medicine
- ADA Standards of Medical Care in Diabetes (2026)
- British Journal of Anaesthesia - Perioperative Diabetes Management Guidelines
- American Society of Anesthesiologists - Practice Guidelines for Perioperative Glycemic Management
🔗 Backlinks
📌 Hashtags
#DiabetesAnaesthesia #PerioperativeCare #GlycaemicControl #SGLT2iSafety #AutonomicNeuropathy #AnaesthesiaGuidelines #PatientSafety #MedicalEducation💬 Share Your Experience!
Have you encountered challenging cases with diabetic patients under anaesthesia? Share your insights in the comments below or tag a colleague who would benefit from this guide!
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