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Perioperative Management of Diabetes a & hesi C st lin e ic n a Azevedo and Machado, J Anesth Clin Res 2019, A l f R o e Journal of Anesthesia & Clinical 10:5 l s e a a n r r c u h o J Research ISSN: 2155-6148 Review Article Open Access Perioperative Management of Diabetes Mellitus: A Review Mariana Raquel Moreira Azevedo1 and Humberto S Machado2,3* 1Department of Anesthesiology, Abel Salazar Institute of Biomedical Sciences, University of Porto, Portugal 2Department of Anesthesiology, University Hospital Center of Porto, Porto, Portugal 3Center for Clinical Research in Anesthesiology, University Hospital Center of Porto, Porto, Portugal *Corresponding author: Dr Humberto S Machado, Department of Anesthesiology, University Hospital Center of Porto, Portugal Largo Professor Abel Salazar, 4099-001 Porto, Portugal, Tel: +351.935848475; E-mail: [email protected] Received date: April 19, 2019; Accepted date: May 24, 2019; Published date: May 31, 2019 Copyright: © 2019 Azevedo MRM, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Abstract Introduction: Diabetes Mellitus (DM) is frequently observed in surgical patients and relates to an increase in perioperative morbidity and mortality. Disease, anesthesia and surgery result in dysglycemia (hypo and/or hyperglycemia), which is one of the worse prognostic factors. The objective of this study is to review the specific needs of the diabetic surgical patient in the perioperative period, regarding its optimization. Methods: Scientific studies (n=89) were obtained through PubMed, Google Scholar and Google, between 2008 and 2018. Results: Actions proposed in order to reduce perioperative complications in the diabetic patient. Preoperative period: an anesthetic evaluation, discontinuation of OADs and fast-acting insulin, prioritization of diabetics in the surgery list, cancellation of non-urgent procedures when there are metabolic abnormalities and poor glycemic control and promotion of gastric emptying due to gastrointestinal autonomic dysfunction. Intraoperative period: the use of IV perfusion of insulin for glycemic control in major surgeries, the use of glycoside sera in cases of prolonged fasting and/or IV insulin perfusion, hourly glycemic monitoring, a glycemic goal between 80-180 mg/dl with correction of hyperglycemias with insulin, and the use of a rapid-sequence intubation when there is risk of aspiration. Postoperative period: the early return to oral nutrition and the restitution of OADs and insulin with the onset of food intake, multimodal analgesia and antiemetic prophylaxis, the correct transition from IV perfusion to subcutaneous insulin and pre-discharge therapeutic optimization. Discussion: Several studies have shown a correlation between dysglycemia and postoperative morbidity and mortality. Nevertheless, the ideal glycemic range and the best glycemic management strategy remain indeterminate. Conclusion: Studies that establish specific measures and universal cut-offs are scarce. There is a need for clearer and guidelines to minimize perioperative complications. It is also important that diabetic patients have the capacity to manage their own disease, to facilitate their optimization in the surgical context. Keywords: Diabetes mellitus; Perioperative management; distinct etiology: type 1 DM, which results from the immune-mediated Anesthesia; Preoperative; Postoperative; Surgery destruction of the cell and leads to absolute insulin deficiency, with type 1 diabetics having a compulsory need for insulin; the type 2 DM, Introduction which is associated with progressive loss of insulin secretion by the cell and insulin resistance, being it possible for type 2 diabetics to be Diabetes Mellitus (DM) is a chronic disease of high prevalence and controlled with diet, oral antidiabetic (ADO) and/or insulin; the increasing incidence, particularly in developed or developing gestational DM, diagnosed in the 2nd/3rd trimester of pregnancy; and countries, and has been identified as a major cause of global mortality the 4th category which includes a broad spectrum of specific types in the last decade [1,2]. In 2015, the estimated prevalence of DM was from other causes, such as genetic defects of cells, diseases of the 8.5% in the world population, and 13.3% in the Portuguese population exocrine pancreas, endocrinopathies and drugs [6,7]. Type 1 and type [3,4]. This multifactorial epidemic is due to the increasing age of the 2 DM are the most frequent types; however, type 2 is the most population and the increase of obesity and sedentarism, and is common (90-95% of cases) and most often develops in elderly and/or expected to continue to increase if some lifestyle habits (such as diet) obese adults, although there is an increase in the diagnosis of young are not modified [2,5]. patients [1,2]. Type 1 DM mainly affected pediatric patients, but is now DM is the most common multisystem endocrine-metabolic disease, frequently diagnosed in adults [8]. characterized by a deregulation in carbohydrate metabolism where The diagnosis of DM is established based on plasma glucose values, hyperglycemia predominates, and, if untreated, can become namely: fasting blood glucose ≥ 126 mg/dl, or glucose 2 h after oral debilitating due to chronic failure of several organs [6]. It is classified glucose tolerance test (OGTT) ≥ 200 mg/dl, or HbA1c ≥ 6.5%, or based on its pathophysiological mechanism, in four clinical types of casual blood glucose ≥ 200 mg/dl in a patient with classic symptoms of J Anesth Clin Res, an open access journal Volume 10 • Issue 5 • 1000893 ISSN: 2155-6148 Citation: Azevedo MRM, Machado HS (2019) Perioperative Management of Diabetes Mellitus: A Review. J Anesth Clin Res 10: 893. Page 2 of 14 hyperglycemia or hyperglycemic crisis (polyphagia, polydipsia, arrhythmias), systolic and diastolic heart failure, congestive heart polyuria, fatigue and weight loss). Thus, another group of patients, failure, and sudden death. Through several mechanisms, known as pre-diabetic patients, can be classified into two groups: with hyperglycemia promotes vasodilation and induces a pro- impaired glucose tolerance (glycemia 2 h after OGTT between 140 and inflammatory, prothrombotic and pro-atherogenic state, responsible 199 mg/dl) or with fasting glucose anomaly (glycemia between 100 and for these common vascular complications. These patients also have 125 mg/dl in the fasted state) [7]. high intraoperative cardiovascular instability, since neuropathy predisposes them to bradycardia, hypotension and cardiorespiratory In DM there are several progressive physiological changes, thus, arrest during general anesthesia, and not the normal response some organs and systems must be emphasized in the anesthetic (vasoconstriction and tachycardia) to the vasodilating effects of approach: musculoskeletal, renal, neurologic, and cardiovascular [9]. anesthesia. DM also predisposes to the development of a specific cardiomyopathy, which leads to diastolic dysfunction. This disease is, Musculoskeletal system therefore, especially in insulin-dependent patients, an independent risk Chronic hyperglycemia promotes non-enzymatic glycosylation of factor for adverse cardiac events, with cardiovascular disease being the proteins and leads to abnormal cross-linking of joint glycogen, which cause of death in 80% of diabetics [5,9,12]. will limit joint mobility, triggering Stiff Joint Syndrome or diabetic The estimated incidence of diabetics requiring surgery is about 25%, cheiroarthropathy, which mainly affects the temporomandibular, which explains why DM is frequently observed in surgical patients atlanto-occipital and cervical spine joints. Diabetic scleredema is [11]. As the incidence of this disease continues to increase, and characterized by a non-depressible hardening of the skin in the neck diabetics more often suffer from macro and microvascular and upper back regions and, associated with reduced joint mobility, complications (including retinopathy, nephropathy and neuropathy) limits the angles of movement of the neck and may hinder orotracheal and other comorbidities, their increased need for surgery and/or other intubation [9]. surgical procedures, compared to non-diabetic patients, is understandable [13]. DM leads to increased morbidity, perioperative Renal system mortality (50% higher than non-diabetic patients) and use of resources, leading to more frequent and prolonged hospitalizations A significant proportion of patients with DM have diabetic [9,14]. The determinants of worse prognosis of diabetics in the nephropathy. This chronic complication is characterized by the perioperative period are many, namely: hypoglycemia and development of albuminuria and progressive reduction of renal hyperglycemia; comorbidities, including micro and macrovascular function in diabetics without adequate glycemic control [9]. complications; the acute complications of diabetes; the complex medication regimens; errors in insulin prescription; the peri and Neurologic system postoperative infections; failure in identifying patients with diabetes; The neurological effects of DM increase the risk of cerebrovascular the lack of adequate institutional therapeutic protocols; and the lack of accidents (CVA) and the presence of hyperglycemia is a strong knowledge from health professionals about the correct approach predictor of worse prognosis in the various forms of acute brain injury
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