Patients with Type I Diabetes suffer from an absolute deficiency of insulin production due to the autoimmune destruction of pancreatic beta cells. This condition predisposes Type I Diabetes patients to various comorbidities, including cardiovascular, renal, and neurological disorders. Consequently, patients with Type I Diabetes undergoing surgery and anesthesia require meticulous and individualized preoperative, intraoperative, and postoperative management to maintain optimal glycemic control and prevent complications.

Effective preoperative management for patients with Type I Diabetes involves careful consideration of their cardiovascular and microvascular health, signs of autonomic neuropathy, and airway status. Most importantly, their absolute insulin deficiency and reliance on exogenous insulin necessitate meticulous preoperative glucose control. This requires taking into account the patient’s baseline glycemic control, home insulin regimen, type of procedure, and expected postoperative recovery (1). The HbA1c test, which evaluates glycemic control over the past 2-3 months, provides important information to the perioperative team. High preoperative HbA1c values (8-9%) are associated with poorer postoperative outcomes, including increased risks of cardiovascular events and mortality. Therefore, optimizing glycemic control before surgery is essential (2). Surgeons, anesthesia providers, and nurses involved in the perioperative care of patients with Type I Diabetes should have a complete understanding of the patient’s health status.

Intraoperative management focuses on preventing hypoglycemia (blood glucose levels less than 70 mg/dL) and hyperglycemia (blood glucose levels above 125 mg/dL while fasting and above 180 mg/dL 1-2 hours after eating). Patients with Type I Diabetes have a higher risk of intraoperative hypoglycemia compared to those with insulin-treated Type II Diabetes, leading to an increased risk of cardiovascular events and mortality (3, 4).

Given the common occurrence of intraoperative dysregulation in Type I Diabetes, basal insulin via a pump or IV drip should never be omitted. Glucose levels should be frequently monitored to avoid catheter occlusion or pump failure, which can lead to ketoacidosis (5). It is generally recommended to maintain blood glucose levels in the range of 90–180 mg/dL. The appropriate insulin administration technique (subcutaneous, intravenous) and infusion rate may vary depending on the procedure length and the patient’s fasting state. For shorter procedures, continuing subcutaneous insulin infusion is recommended, with a suggested reduction of the basal infusion rate by 20-30% preoperatively, especially if the patient has a history of hypoglycemic episodes (1, 3, 5). For longer procedures (greater than 2 hours), switching to intravenous insulin infusion is safer due to potential increased insulin requirements and issues with subcutaneous insulin absorption (3).

Most intravenous induction agents have minimal effects on glycemic control, but some drugs can interfere with continuous glucose monitoring (CGM) readings. Therefore, it is recommended to confirm CGM readings with standard laboratory or certified point-of-care testing before making clinical decisions in the perioperative period (3).

In the 24-48 hours after surgery and anesthesia, patients with Type I Diabetes require close monitoring of blood glucose levels as insulin requirements may change due to nausea, stress, pain, and/or inactivity. Patients may require supplemental insulin infusions or increased basal insulin doses to manage surgical stress-induced hyperglycemia or intravenous glucose if experiencing hypoglycemia (2). Coordination with the endocrinology team is recommended for a smooth transition back to the patient’s home regimen.

Perioperative management of patients with Type I Diabetes requires a multidisciplinary approach, careful planning, and vigilant monitoring of glycemic control. Anesthesiologists play a key role in selecting appropriate anesthetic techniques, administering insulin, and coordinating care to minimize complications and optimize outcomes for patients with Type I Diabetes during surgery.

References

1. American Diabetes Association Professional Practice Committee, and American Diabetes Association Professional Practice Committee:. “2. Classification and diagnosis of diabetes: Standards of Medical Care in Diabetes—2022.” Diabetes care 45.Supplement_1 (2022): S17-S38.
2. Karunarathna, Indunil, et al. “Comprehensive Management of Diabetes Mellitus in the Perioperative Setting: An Anesthesia Perspective.” Uva Clinical Lab. Retrieved from ResearchGate (2024).
3. van Wilpe, Robert, et al. “Type 1 and other types of diabetes mellitus in the perioperative period. What the anaesthetist should know.” Journal of Clinical Anesthesia 84 (2023): 111012.
4. Dogra, Prerna, Catherine Anastasopoulou, and Ishwarlal Jialal. “Diabetic perioperative management.” StatPearls [Internet]. StatPearls Publishing, 2024.
5. Polderman, J. A. W., J. Hermanides, and A. H. Hulst. “Update on the perioperative management of diabetes mellitus.” BJA Education (2024).
6. Crowley, Kieran, et al. “Current practice in the perioperative management of patients with diabetes mellitus: a narrative review.” British journal of anaesthesia 131.2 (2023): 242-252.

Related posts:

Biological Mechanisms of Coronavirus Telemedicine: Past, Present, and Future Effectiveness of Progressive Mobility Programs on the Functional States of ICU Patients Anesthesia Considerations for Dialysis Patients