Diabetes

Question 1

Although there are no validated HbA1c cut-off values, it may be plausible to postpone an elective surgery if HbA1c is higher than ___%.

Answer 1

10%

Question 2

__(1)__ can lead to the development of lactic acidosis in cases of renal dysfunction or with the use of intravenous contrast.
__(2)__ and other insulin secretagogues risk hypoglycemia,
__(3)__ carry the risk of euglycemic ketoacidosis in fasting, or acutely ill patients,
___(4)__ can worsen nausea and vomiting by delaying gastric emptying.

Currently, the recommendations are for holding these medications on the day of surgery except for __(5)__, which should be held a minimal 24-hours before surgery

Answer 2

(1) Metformin
(2) Sulfonylureas
(3) Sodium-glucose cotransporter-2 (SGLT-2) inhibitors
(4) Glucagon-like-peptide-1 receptor (GLP-1) agonists
(5) SGLT-2 inhibitors

Question 3

Patients who are on home insulin therapy should reduce the dose of long-acting basal insulin (glargine, detemir) by __(1)__ the evening before surgery.If they routinely take basal insulin only in the morning, then the reduced dose should instead be administered on the morning of surgery.

Patients who are on twice daily glargine or detemir should reduce the dose by __(2)__ in the evening prior to as well as the morning of surgery.

However, in patients who take high doses of basal insulin (>60% of total daily insulin) or total daily insulin dose is greater than 80 units or are at high risk of hypoglycemia (elderly, renal or hepatic insufficiency, prior hypoglycemic episodes); basal insulin dose should be reduced by __(3)__ to minimize hypoglycemia risk.

Answer 3

(1) 20 -25%
(2) 20 - 25%
(3) 50 - 75%

Question 4

T or F: For the ultra-long-acting insulin, owing to their long half-life, dose reductions should be made three days before surgery with the help of an endocrinologist or diabetes care team.

Answer 4

True

Question 5

In cases of intermediate-acting insulin such as neutral protamine Hagedorn (NPH), what dose is given the night before and on the morning of surgery?

Patients who are on premixed insulin (NPH/Regular 70/30, aspart protamine/aspart 75/25, etc.), should preferably receive long-acting insulin the evening prior instead of their premixed formulation. However, this may not be feasible in a lot of these patients. In such scenarios, the premixed insulin is reduced by 50% on the morning of surgery, followed by the initiation of dextrose-containing intravenous solutions. Alternatively, these patients can be asked to skip the morning dose and arrive early to the preoperative area where they can receive a long-acting formulation.

Answer 5

(1) Usual dose evening prior and reduction of 50% on morning of surgery.

Question 6

Hyperglycemia (over 180 mg/dl), in surgeries of shorter duration (<less than 4 hours) with expected hemodynamic stability and minimal fluid shift, can be managed how? (1)

In surgeries that may involve hemodynamic fluctuations, massive fluid shifts, or last longer than 4 hours duration, BG greater than 180 mg/dl should be managed with intravenous insulin infusion, and BG monitored every 1 to 2 hours.

Answer 6

(1) With two, hourly subcutaneous correctional insulin (rapid acting) and BG checks.