Preoperative optimization of diabetes

Abstract

As of 2018, there were an estimated 34.2 million diabetic patients in the United States with 7.3 million of them remaining undiagnosed. 1 Worldwide there are as many as 493 million people living with diabetes and this number is predicted to increase to 700 million by 2045. 2 Diabetes has a profound impact on quality of life and financial stress for patients as they incur medical costs, which are on average more than 2 times that of nondiabetic patients and are more likely to incur catastrophic health care expenditures. 3 Diabetic patients require surgical interventions more frequently than their nondiabetic counterparts and often face a myriad of perioperative complications including increased risk of kidney injury, postoperative infection, thromboembolic events, and cardiovascular morbidity and mortality. [4][5][6][7] Hyperglycemia has been implicated in increased length of hospital stay and resource utilization in surgical patients and improved glycemic control may lead to mitigation of both cost and postoperative complications. [8][9][10][11] Preoperative glycemic control is often challenging to achieve given the complexity of managing nil per os (NPO) guidelines, enhanced recovery after surgery protocols, and surgical stress, all of which can lead to fluctuating glucose levels in surgical patients. Outpatient diabetic management is becoming more complex with the introduction of newer oral antihyperglycemic agents such as sodium-glucose co-transport (SGLT-2) inhibitors and with the increasing use and sophistication of insulin pumps and continuous glucose monitors. The preoperative encounter provides a unique opportunity to identify undiagnosed diabetic patients, optimize glycemic control, and mitigate periprocedural risk.