Anesthesia providers, and medical professionals in general, often care for patients who have preexisting chronic conditions such as hypertension, high cholesterol or a history of cancer. These patients may be at higher risk for complications, or may be using medications that interfere with anesthesia administration.1 Diabetes is a common disease that anesthesia providers must confront during the perioperative period; researchers estimate that approximately eight percent of the United States population has diabetes at any given time.2 Patients with diabetes require specialized care throughout surgery, as suboptimal diabetes control can cause adverse perioperative outcomes.3 Oftentimes, this special care involves insulin pump therapy that is maintained before, during and after surgery.4 In order to provide the best care to their patients, anesthesia providers must understand the pathology of diabetes, the function of insulin pumps and proper perioperative insulin pump management.
Diabetes occurs when the pancreas does not produce enough—or any—insulin to help glucose get from the blood to cells to be used as energy.5 Because the body is unable to adequately process sugars, one of the characteristics of diabetes is hyperglycemia (high blood sugar).5 Over time, hyperglycemia can lead to problems such as heart disease, stroke, kidney disease, eye and vision problems, dental disease, nerve damage and foot infections.5 It is crucial to control diabetes during the perioperative period, as blood sugar variations can cause complications such as hyperglycemic crisis, postoperative infection, poor wound healing and even mortality.3 In order to prevent hyperglycemia, many patients with diabetes use continuous subcutaneous infusions of insulin (also known as insulin pump therapy).6 In fact, an estimated 400,000 patients with diabetes in the United States use insulin pumps to control blood glucose.7 Because high intensity insulin infusion can cause low blood sugar, some patients accompany their insulin pumps with continuous glucose monitoring systems.6 Additionally, a disadvantage of insulin pump therapy is that it only infuses short-acting insulin, so disconnection, occlusion or cessation of therapy will make the patient completely insulin deficient within four hours.4 Overall, the anesthesia provider’s duties to monitor and control vital signs throughout surgery are more complex for patients with diabetes.
Before surgery, the anesthesia provider must consult with the patients and other health professionals to ensure proper glycemic control throughout the entire perioperative period.4 This includes communication with the specialist pump diabetes team, endocrinologist and patient to create a management plan for the patient’s procedure and hospital stay.4 Also, a preoperative medical history must be performed to identify comorbidities, such as cardiovascular disease and neuropathy, which could affect the surgical outcome.8 If all parties decide to go through with surgery, the anesthesia provider should aim to establish glycemic control (i.e., HbA1C less than 8.5 percent) before proceeding.4 This entails close, frequent glucose monitoring and use of various types of short- and long-acting insulin.4 For example, a paper by Marks recommends discontinuation of long-acting insulin one to two days before surgery, subsequent glucose stabilization with intermediate insulin mixed with short-acting insulin and recontinuation of long-acting insulin the day before surgery.8 Furthermore, preparation for surgery will entail a basal test to establish a stable fasted blood glucose concentration.4 Meanwhile, Boyle et al. stress the importance of caring for the insulin pump itself.7 They suggest inspecting the pump insertion site before the procedure to make sure it is not displaced throughout surgery.7 For emergency procedures, it may be prudent to remove the insulin pump and use intravenous insulin infusion to control blood glucose levels.7 Clearly, the anesthesia provider must engage in thorough communication, planning and decision-making before surgery for a patient with an insulin pump.
Intraoperative procedures focus on blood glucose management. When the patient arrives at the operating room, the anesthesia provider will confirm that the insulin pump is functioning and intact.7 If the pump itself is placed in the body area where surgery will occur, the anesthesia provider is responsible for administering anesthesia throughout the procedure.7 Boyle et al. recommend checking blood glucose levels every hour during surgery and providing insulin doses when necessary.7 Throughout the procedure, the anesthesia provider must maintain the patient’s target blood glucose level, which is based on the preoperative evaluation of fasted blood sugar.4,8 Other important intraoperative goals include preventing other metabolic disturbances or electrolyte imbalances.8 Additionally, the anesthesiology professional must ensure the patient’s insulin pump does not move or lose function during surgery.7 As patients with diabetes may have other conditions, anesthesia providers must be especially aware of signs of cardiovascular or respiratory changes.8 Overall, glucose control and vital signs monitoring are crucial to intraoperative success.
During the postoperative period, glucose control remains key to managing a patient who uses insulin pump therapy.4 During recovery, blood glucose monitoring should be continued hourly until the patient is conscious and capable of managing the pump (or, in the case of pediatrics, the patient’s guardian can manage the pump).4 The pump should be inspected to ensure proper placement and function, as it may have shifted throughout surgery.7 The patient should be aware of any significant changes in blood sugar, which could reflect disconnection of the pump or a bodily response to surgical stress.7 Insulin infusion should continue while patients are on a liquid diet to avoid hypoglycemia.8 Also, the clinician should watch closely for signs of hyperglycemia-related surgical site infection.8
Perioperative care for a patient with an insulin pump is complex. Before a procedure, the anesthesia provider must communicate with the patient’s endocrinology and pump management teams, evaluate the patient for common comorbidities, establish glycemic control and ensure proper function of the pump. During and after a surgery, the anesthesia provider will be responsible for vital signs monitoring, infection prevention, glucose control and even insulin administration. Future studies and policies should focus on efficacious documentation of insulin pumps throughout surgery and aim to standardize perioperative care across all patients using insulin pump therapy.7
1.Lefor AT. Perioperative management of the patient with cancer. Chest. 1999;115(5 Suppl):165S–171S.
2.Moghissi ES, Korytkowski MT, DiNardo M, et al. American Association of Clinical Endocrinologists and American Diabetes Association consensus statement on inpatient glycemic control. Diabetes Care. 2009;32(6):1119–1131.
3.Leung V, Ragbir-Toolsie K. Perioperative Management of Patients with Diabetes. Health Services Insights. 2017;10:1178632917735075.
4.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. BJA: British Journal of Anaesthesia. 2015;116(1):18–26.
5.National Institute of Diabetes and Digestive and Kidney Diseases. What is Diabetes? Diabetes Overview December 2016; https://www.niddk.nih.gov/health-information/diabetes/overview/what-is-diabetes.
6.Umpierrez GE, Klonoff DC. Diabetes Technology Update: Use of Insulin Pumps and Continuous Glucose Monitoring in the Hospital. Diabetes Care. 2018;41(8):1579–1589.
7.Boyle ME, Seifert KM, Beer KA, et al. Guidelines for application of continuous subcutaneous insulin infusion (insulin pump) therapy in the perioperative period. Journal of Diabetes Science and Technology. 2012;6(1):184–190.
8.Marks JB. Perioperative management of diabetes. American Family Physician. 2003;67(1):93–100.