Malaysian Journal of Medicine and Health Sciences (eISSN 2636-9346)

REVIEW ARTICLE

Anesthesia Management on Perioperative With Dm Patients: A

Literature Review
Made Suandika1, Wilis Sukmaningtyas1, Amin Susanto1,Woung Ru-Tang2, Dwi Astuti3
1
Department of Anesthesia, Faculty of Health Science, Harapan Bangsa University, Purwokerto 53182, Indonesia
2
School of Nursing College of Medicine Chang Gung University, Taoyuan City 333,Taiwan
3
School of Nursing Politeknik Yakpermas Banyumas, Central Java 53181, Indonesia

ABSTRACT

Diabetes Mellitus (DM) is a global burden. The aim of this work was to conduct a literature review that highlighted
some of the most recent innovations based on the evidence foundation by identifying the standard textbooks in
general. We utilized PubMed to search various databases, including Medline (January 2011 to June 2021), Google
Scholar and Science Direct. Articles providing a decent methodological design were selected after the bibliographic
survey. English seems to have its limitations. We found ten papers from France, Bangladesh, Portugal, the USA, as
well as other countries that reflected our study material. The success of anesthetic management in DM patients was
determined by managing pre-anesthesia blood glucose levels by setting a target for normal glucose levels and inten-
sively monitoring glucose levels during and after surgery, which also determines the success of anesthetic manage-
ment in DM patients. The predominance of postoperative complications requires thorough blood sugar monitoring
during perioperative anesthesia to minimize the risk of hypo/hyperglycemia.

Keywords: Anesthesia management, Perioperative, Diabetes mellitus

Corresponding Author: Olivera (7) found a prevalence of hyperglycemia with

Made Suandika, PhD values of 180 mg/dl as high as 32% in both ICU and non-
Email: [email protected] ICU patients in studies involving >3 million patients in
Tel: +6282146935020 >500 hospitals in the United States (7) .However, more
than 30% of patients with postoperative fluctuating
INTRODUCTION hyperglycemia, also known as situational stress
hyperglycemia, had no prior history of diabetes (8).
Diabetes mellitus (DM) is a major comorbid condition
that affects people throughout their lives. The global On the other hand, the trend toward the risk of
incidence of diabetes mellitus is rapidly increasing perioperative complications associated with diabetes
and has a detrimental impact on human existence; it is mellitus is debatable, with perioperative mortality
anticipated that, by 2025, the number of persons affected rates up to 50% higher than in the population (5). The
will have risen to almost 300 million. (1,2) Incidence problem of persistent hyperglycemia can lead to a variety
of diabetes grew from roughly 1.7% in the 2000s to of consequences, including cardiovascular disease,
a highly changing estimate (4.4 %) in 2030. (3) DM nephropathy, retinopathy, neuropathy, and a variety
affects 425 million adults over the age of 18 worldwide, of lower extremity diseases, making glycemic control
according the International Diabetes Federation, with crucial in DM (5). This condition is often associated
the incidence expected to rise by 35% by 2045 (1,4). with poorly controlled medication side effects such
as hyperglycemic failure, including comorbid micro
Perioperative care is often faced by patients with and macrovascular complications, insulin prescribing
comorbidities such as DM, causing many systemic errors, increased perioperative infection episodes
diseases that require surgical treatment that must associated with hypoglycemia and hyperglycemia,
be controlled properly and correctly (5). The risk of lack (or inadequate) protocols for managing inpatient
postoperative failure can occur at a higher level than diabetes and inadequate knowledge of diabetes and
non-diabetic patients. In addition, the incidence of hyperglycemia management among staff providing care
hyperglycemia has negative consequences on all organ (2,9–12).
systems of the body (6). Perioperative hyperglycemia is
reported in 20 to 40% of patients undergoing general Moreover, perioperative anesthesia can result in acute
surgery and the risk increases in about 80% of patients perioperative problems including dehydration (osmotic
after cardiac surgery (1). diuresis), acidosis (increased lactate and ketones),

Mal J Med Health Sci 18(SUPP3):294-302, Feb 2022 294

Malaysian Journal of Medicine and Health Sciences (eISSN 2636-9346)

tiredness, and weight loss (lipolysis, protein catabolism) is no more recently published material, were included
(12,13). Although there are several reviews that discuss in order to reflect current therapeutic practice, because
how to treat patients with DM in the surgical field, it there are no evidence-based guidelines for the best
is still often confusing so that the consideration of perioperative care for diabetic individuals. Several
assumptions and arguments in this situation needs to be management methods are discussed in this overview,
developed and emphasized (14–16). based on what has been published internationally.

Due to the growing phenomena of methodological RESULTS

variety in both education and practice as nurse
anesthetists, it is vital to explore this topic in order Of the 349 studies identified by our literature search,
to provide solutions to these questions (17–19). eight met the inclusion criteria; the screening diagram
Understanding the pathology of diabetes and the value using PRISMA guidelines shows the process of searching
of new studies could help diabetic surgical patients and selecting the literature (Figure 1). It is important to
experience better perioperative care. This review will go consider that perioperative diabetes management is
over some of most recent developments in the field as given to someone who is familiar with its complexities.
well as how to handle diabetic patients perioperatively. In this study, it was found that two papers come from
This review will not provide a management algorithm. France (20) and the USA (8) which described several
views of the perioperative management guideline for
METHOD diabetes mellitus patients in general, while eight papers
come from Bangladesh (21), Portugal (7), the UK (2),
We searched several databases, including Medline via Georgia (4), Greece (9), and Brazil (5) which described
PubMed and Google Scholar (January 2011 to June the views of the basic concept on perioperative treatment
2021), the Cochrane Library, and Lilacs (from 2011 to in DM patients.
June 2021). After the bibliographic survey, the articles
with the better methodological design were selected.
We also use evidence-based updates from the UpToDate
and Medscape domains.

Google Scholar and ScienceDirect databases were

searched using the terms Diabetes Milletus anesthesia
surgery, Diabetes postoperative anesthesia, DM
preoperative anesthesia, Diabetes perioperative
management, Diabetes anesthesia management, and
Diabetes anesthesia. The types of articles used in
this work: reviews, systematic reviews, case reports,
guidelines, and observational studies.

Searches were conducted between January 2011 and June

2021. The following strategies were used for searches
in PubMed: ‘’Diabetes Mellitus’’ AND ‘’Anesthesia’’,
‘’Diabetes Mellitus’’ AND ‘’Perioperative’’, ‘’Glycemic
Conditions Control’’ AND ‘’Perioperative Care’’,
‘’Glycemic Control’’ AND ‘’Anesthesia’’, ‘’Diabetes
Mellitus’’ AND ‘’Anesthesia’’ AND; ‘’Diabetes
Figure 1: PRISMA flow diagram showing literature search re-
Mellitus’’ AND ‘’Anesthesia’’, ‘’Diabetes Mellitus’’
sults
AND ‘’Perioperative’’, ‘’Anesthesia’’. To find studies on
diabetes and perioperative care, a manual search was
also conducted to locate unquoted papers in electronic Service standards for DM patients are needed in order
journals and research references. The following are the to obtain effective management results, and can reduce
requirements for inclusion: English-language studies, the incidence of DM complications. Perioperative
studies on the practice of glycemic control in adult diabetic care requires a comprehensive collaboration from
patients who have surgery, independent of the type of multidisciplinary aspects (anesthesiologists, nutritionists,
operation were conducted. We also conducted a simple surgeons, nurses, psychologists, etc.), so that the needs
technique search because there were some articles that of each perioperative patient can be met properly
were not cited online in journals or bibliographies, and (5,8,9,20). This recommendation does not describe
we added inclusion criteria such as studies on glycemic all clinical situations in the field, nor is it intended to
management in adult diabetes patients having surgery, replace local policy protocols, and will require revision
independent of kind of operation, published in English. in future practice and can be used for considerations in
Recently published studies, regardless of whether there making decisions (2,22–24).

295 Mal J Med Health Sci 18(SUPP3):294-302, Feb 2022

 Malaysian Journal of Medicine and Health Sciences (eISSN 2636-9346)

DM is a set of symptoms induced by an increase in The WHO (31,33,34) also recommends that the diagnosis
blood glucose (BG) levels as a result of a gradual of diabetes mellitus be made when the plasma glucose
decrease in insulin secretion, which can occur as a concentration is greater than 11.1 mmol/L (whole
result of insulin resistance (5,6,10,25). According to the glucose concentration in venous blood is greater than
American Diabetes Association (ADA) (12) in 2019, DM 10 mmol/L) (34). Furthermore, a diagnosis of diabetes is
is a collection of metabolic illnesses with distinctive made when the fasting plasma glucose concentration is
hyperglycemia that arises owing to changes in insulin greater than 7 mmol/L at two different periods or when
production, insulin action, or both (12,25). If a person an oral glucose tolerance test is performed. Aside from
has classic symptoms, including polyuria, polydipsia, that, if the results of the oral glucose tolerance test are
and polyphagia, as well as a blood sugar level of 200 greater than 11.1 mmol/L, diagnosis of diabetes mellitus
mg/dl and a fasting blood sugar of 126 mg/dl, they are can be made (11,16,18,25).
diagnosed with diabetes (1,8,11,25–27).
The diagnosis of DM can be enforced in three ways:
DM Classification First, if a complaint is discovered, a BG check of 200
Type 1 and type 2 diabetes mellitus are heterogeneous mg/dL is adequate to confirm the diagnosis of DM
diseases because the clinical manifestations and course (13,15,35). For benchmark DM diagnosis, the second
of the disease can vary (15,25,26). Determination of result of fasting BG levels of 126 mg/dL is also used. (34)
classification is very important to determine therapy, but The findings of the testing of glucose levels in new blood
there are some individuals who cannot be classified with once are not normal for the group without symptoms
certainty as to whether having type 1 diabetes or type 2 indicative of DM, although they are strong enough to
diabetes at the time of diagnosis. The old paradigm that establish a clinical diagnosis of DM (36,37). Further
type 2 diabetes only occurs in adults and type 1 diabetes validation is required in this scenario by obtaining the
only occurs in children is no longer used because both number no normal, a good fasting BG level of 126 mg/
types can occur at any age (24). dL, or BG levels of 200 mg/dL on other days, or from
aberrant oral glucose tolerance test results. The last one,
Diagnosis of DM determined by the Oral Glucose Tolerance Test (OGTT),
The diagnosis of DM is made on the basis of checking has 2-hour plasma glucose levels of less than 200 mg/dL
BG levels (20). In 2005, the WHO recommended that, (11.1 mmol/L). The OGTT must be performed according
as our guideline, the current WHO diagnostic criteria to WHO guidelines, with a glucose load of 75 grams of
for diabetes should be maintained at fasting BG level of glucose anhydrous dissolved in water (37–39).
7.0 mmol/l (126 mg/dl) or plasma glucose for 2 hours –
11.1 mmol/l (200 mg/dl) dl) (16,25,27,28). Despite the Preoperative Management
limitations of the data on which the diagnostic criteria The type of diabetes, glucose control, diagnostic time (a
for diabetes are based, the current criteria distinguish predictor of chronic problems), pharmacological therapy
between groups with increased premature death and (oral, noninsulin, or insulin injectable antidiabetic
increased risk of microvascular and cardiovascular medicines), dose and timing of drug administration
complications (1). On the other hand, the recommended should all be clarified during the initial examination
BG test is an enzymatic glucose test using venous plasma of DM patients.(40) The disorder’s dangerous risk
blood (7,13,27). factors for arterial blockages should be identified (sleep
deprivation, poor lifestyle such as smoking, lack of
The results of treatment can be monitored by using a exercise, hypertension, dyslipidemia, family history)
BG meter to perform capillary BG checks (29). The (11,18). Communication with the patient and family
diagnosis cannot be made based on the presence of prior to surgery is critical for confirming preoperative
diabetes. Various complaints can be found in DM insulin and fasting instructions (1,28,41,42). For all non-
patients. If presented with typical complaints, such emergency treatments, the patient should fast for up
as polyuria, polydipsia, polyphagia, and unexplained to two hours before the procedure, glucose-free clear
weight loss, the possibility of DM should be considered fluids should be recommended to prevent hypovolemia,
DM (4). Other accompanying complaints are weakness, and sugar-containing clear fluids should be considered
tingling, itching, blurred eyes and erectile dysfunction in to treat hypoglycemia (38,43,44).
men, and genital itching in women (4,7,18).
Acceptance of patients undergoing elective surgery
The ADA states (30,31) that, when the BG level of should take place 1-2 days prior to surgery to ensure that
symptomatic patients is more than 11.1 mmol/L, the the goal BG value is met (18). If the patient’s BG value
diagnosis of DM must be established. Symptomatic is in the 180 mg/dl range, surgery can be scheduled
patients with fasting BG> 7 mmol/L (6.1 mmol/L BG) without further care, but if the number is between 181-
will be reviewed at another day (25). If it is still higher 300 mg/dl, an insulin pump may be considered before
than the limit, DM will be diagnosed (11,12,32). The surgery (39,40,44,45).
ADA defines fasting BG between 6.1 and 7.0 (5.6-6.1
concentration BG) as impaired fasting BG (12). In addition to the incidence of hyperglycemia, the

Mal J Med Health Sci 18(SUPP3):294-302, Feb 2022 296

Malaysian Journal of Medicine and Health Sciences (eISSN 2636-9346)

frequency of hypoglycemia must be assessed since it surgery lasts >2 hours and requires a long postoperative
interferes with preoperative medication management, fasting time) so that a DM patient, should be listed first
as well as the frequency of hospitalization for glycemic for surgery, shortening the preoperative fasting period
control (acute decompensation) (3,4,46). The patient’s and allowing food consumption. The fasting period
ability to measure his blood sugar and comprehend the for solid foods should last at least six hours, and the
concepts of diabetes medication should be assessed, as it fasting period for clear fluids (no milk, no carbonated
has an impact on their perioperative management (2,24). beverages) should last at least two hours (2,5,9).
The HbA1c test (hemoglobin A1c/glycohemoglobin) is
highly recommended in pre-anesthesia preparation for Diabetes patients may have regional or general
DM patients because it is an examination that measures anesthesia, but any type of anesthetic helps reduce
the average HbA1c or glycosylated hemoglobin level the stress reaction to surgery (5). For example, spinal
over three months, indicating how well BG has been or epidural anesthetic boosts catecholamine secretion,
controlled for the previous three months(40,47,48). preventing hyperglycemia and ketoacidosis, and this
effect might extend for several days after surgery, but
The following are the categories of HbA1c results, it can also create difficulties (28). Because severe
according to the American Diabetes Association: 6.0% hypoglycemia impairs consciousness, recovery from
for normal HbA1c, 6.0–6.4% for prediabetes, and 6.5% general anesthesia may be delayed. Beta blockers raise
for diabetic HbA1c. As a result, for persons who have blood sugar levels in those who don’t have diabetes, but
diabetes mellitus, in general, it is expected that good they also interfere with glucose homeostasis and hide
therapy would result in a positive outcome; HbA1c hypoglycemia symptoms in diabetics (1).
levels can fall to 6.5% (49–52).
To lessen the risk of stomach acid aspiration, patients
If the HbA1c test result is over the usual range, it with suspected gastroparesis should be given prokinetic
indicates the need to adopt diabetes-related lifestyle medications before receiving general anesthesia.
adjustments.(53) Meanwhile, the previous treatment Furthermore, the optimum hemodynamic regimen
for diabetes patients must be adjusted to the condition. should be applied on a continuous basis, with the
Changes in treatment are most likely to include the type understanding that hypotension can occur in diabetic
of medicine used and the dosage (23). autonomic neuropathy (1,2,23,29). During the
intraoperative stage, hemodynamic monitoring, which
The diabetes state of the patient, as well as surgical risk includes blood pressure, pulse, body temperature,
factors, should be assessed. The anesthetic method to and respiratory blood pressure, is performed every
be utilized, the specifics of the surgery to be done, and five minutes to avoid unexpected spikes, which might
laboratory values are all significant considerations.(54) further damage the ocular vessels and put the patient’s
Potential difficulties must be recognized, treated, and overall condition in jeopardy. Regularly checking skin
stabilized before surgery in the case of elective surgery. color and body temperature aids in the early detection of
The major goal of preoperative evaluation is to assess hypoglycemia (2,29). Precautions to take during surgery,
metabolic control and diabetes-related comorbidities both during anesthesia and surgery, include that aseptic
such as cardiovascular disease, autonomic illness, and sterile technique must be strictly adhered to in
neuropathy, and nephropathy (52,55). order to avoid problems, infection risk, and neuropathy
(2,5,7,9).
Furthermore, cardiovascular system abnormalities
such as ischemic events must be considered; therefore, Other considerations need to identify the administration
all DM patients should be tested at least with an ECG of general anesthesia and the type of anesthetic induction
echocardiogram.(3) Patients with diabetic autonomic drug, such as propofol, that will be responsible for the
neuropathy are more likely to develop perioperative decreased lipid metabolism ability in DM patients;
hypotension, thus there is a need to look for resting therefore, the drug should be used with caution. A
tachycardia, peripheral neuropathy, and orthostatic single dose of propofol is thought to be almost risk-
hypotension. To rule out the likelihood of diabetic free; however, prolonged intravenous/bolus/infusion
nephropathy, serum urea and creatinine clearance level for sedation in intensive care may raise the risk of
(CCR) should be assessed. Acute renal failure is more hyperlipidemia (4,5,24,25).
likely in diabetic people with inadequate creatinine
clearance or proteinuria (49,56,57). Furthermore, because DM patients usually have difficulty
with their airways (stiff joint syndrome), the intubation
Intraoperative Management protocol needs professional talents and experience with
Patients with diabetes should be treated with great these conditions, and the patient’s quality of life will
care, with intraoperative considerations and the use of increase significantly (1,5).
anesthetics and analgesics in the intraanesthetic induction
phase used sparingly. Analgesia and anesthesia are used a. Type 1 DM: If morning BG is at least 126 mg/dL,
to assist prevent stress hyperglycemia (21,26). Major half of the whole morning insulin should be given

297 Mal J Med Health Sci 18(SUPP3):294-302, Feb 2022

 Malaysian Journal of Medicine and Health Sciences (eISSN 2636-9346)

subcutaneously. Blood sugar levels should be tested one result in a daily starting basal dose of 30 units of insulin
hour before surgery, at least once during operation, and (65). Dedicated pharmacists or diabetic specialists are
every two hours afterward. When the patient begins to available at some hospitals to assist with the transition
eat, routine insulin delivery begins(58). from IV to subcutaneous insulin. It has been established
that using a specialized team to manage diabetes in
b. Type 2 DM: Blood sugar should be monitored one patients reduces readmission rates by 30 days, lowers
hour before surgery and at least once throughout the diabetes inpatient costs, and improves follow-up and
procedure, and the oral hypoglycemic regimen stopped transition to care. Furthermore, if the diabetic team is
on the day of surgery. If the morning blood sugar level is consulted during the first 24 hours of admission, the
at least 126 mg/dL, patients previously receiving therapy length of stay is greatly reduced (28).
insulin should have subcutaneous insulin injection
with a dose equal to half of the whole morning dose In hospitals, insulin therapy is still the standard of care.
(55,59,60). Blood sugar levels need to be tested after During the perioperative period, there will be two
surgery. If the patient’s blood sugar level is at least groups of diabetic patients: those who were previously
150 mg/dL in the morning (other sources 126 mg/dL), on insulin and those who were not. Table I summarizes
patient insulin is usually given at half dose SC morning the various insulin kinds, as well as their onset and
administration, followed by infusion glucose 5% 1.5 cc/ duration of action, and divides them into basal and bolus
hour. categories for use in the following lectures (40,41).

Next, in the operating room, isolate other IV access for For glucose control, patients with diabetes who have
a 5% dextrose infusion from other fluid administration been treated with subcutaneous insulin, oral medicines,
channels. Check blood sugar every two hours or non-insulin injectable therapy but do not require
commencing after insulin administration, every one IV insulin infusions, frequently require basal insulin
hour intraoperatively, and 2-4 hours after surgery therapy in the hospital (1,5,20). If basal insulin demands
(10,14,21,32). When the patient’s blood sugar falls are unknown, 0.1 to 0.25 units/kg/day is a good place
below 100 mg/dL, dextrose supplements should be to start (66). Patients with insulin sensitivity (BMI type
given (every ml of 50% glucose can boost BG by about 1), the elderly, or having poor renal function should be
2 mg/day dL in adults weighing 70 kg). If intraoperative started at the lower end of the range. Obese or insulin-
hyperglycemia (>150-180 mg/dL) arises, intravenous resistant patients often require larger basal insulin doses.
insulin can be given at a dose utilizing a sliding scale. When the patient is eating well, pre-meal insulin (0.1
One unit of insulin can reduce blood sugar levels by 20 to 0.25 units/kg/day, or 0.03 to 0.08 units/kg/meal) is
to 30 milligrams per day (61–64). frequently required (67).

Postoperative Management DISCUSSION

Patients who require an IV insulin infusion may be
changed to subcutaneous insulin if the infusion rate is The perioperative care of diabetes is a difficult process
constant and glucose control is achieved, especially if a that is best conducted by a multidisciplinary team
diet has been started. Because the half-life of IV insulin because it is dependent on numerous factors. When
is so short, subcutaneous insulin must be given before it comes to the impact on morbidity and mortality,
the IV insulin is stopped (45). Despite the fact that the avoiding swings in BG levels perioperatively is just as
rate of infusion during fasting is a good predictor of basal critical as maintaining low BG levels. The American
subcutaneous insulin demand, doctors often reduce the Diabetes Association (2015) recommends that blood
dose by 20% when converting (46). glucose levels in hospitalized patients be kept below
>180 mg/dl at all times. Many treatment techniques are
If a patient needs 1.5 units of IV insulin per hour overnight, currently established on each hospital’s protocol; for
their basal insulin requirement is around 36 units per example, patients who get subcutaneous insulin have
day. Lowering it by 20%, on the other hand, would their schema maintained during their hospital stay.
Table I: Recommendation for insulin control preoperatively and postoperatively for individuals who are already on insulin.
Medication Preoperative Postoperative

Basal Insulin Long-Acting: Reduce the dose by 20–25 percent the night before or the day Continue reduced dose while NPO
of operation.
Half-dose NPH (intermediate-acting)
All daily dosages are premixed, and the basal insulin is half as long-act-
ing.
All of your insulin should be pre-mixed.
Prandial If there is indications of over-covering on the day before surgery, reduce Hold until there is reliable prandial
Insulin coverage for the last meal. intake
The day of operation will be postponed.
NPO, nothing per Oral.
NPH, Neutral Protamine Hagedorn

Mal J Med Health Sci 18(SUPP3):294-302, Feb 2022 298

Malaysian Journal of Medicine and Health Sciences (eISSN 2636-9346)

However, there is consensus on matters such as placing 4. Duggan E, Carlson K, Umpierresz G. Metabolic
diabetic patients first on the operating list, perioperative Consequences of Surgical Stress. Anesthesiology.
blood glucose monitoring, the efficacy of intravenous 2017;(March):1–14.
insulin and/or glucose solutions, and resuming food 5. Pontes JPJ, Mendes FF, Vasconcelos MM, Batista
intake as soon as feasible postoperatively. The practices NR. Evaluation and perioperative management of
discussed in this review are neither comprehensive patients with diabetes mellitus. A challenge for the
nor detailed; for example, we have not addressed the anesthesiologist. Brazilian J Anesthesiol (English
broad principles of perioperative care, or patients who Ed [Internet]. 2018;68(1):75–86. Available from:
are given corticosteroids, receive parenteral nutrition, http://dx.doi.org/10.1016/j.bjane.2017.06.002
or have renal impairment. Because most studies have 6. Cheisson G, Jacqueminet S, Cosson E, Ichai
looked at perioperative diabetes care in patients C, Leguerrier AM, Nicolescu-Catargi B, et al.
undergoing cardiac surgery or in critically sick patients, Perioperative management of adult diabetic
further study is needed to determine which therapies are patients. Review of hyperglycaemia: definitions
best for patients with diabetes who are undergoing other and pathophysiology. Anaesth Crit Care Pain
operations, such as general surgery. In any case, each Med [Internet]. 2018 [cited 2021 Jul 26];37:S5–
treatment plan, both surgical and non-surgical, must be 8. Available from: https://doi.org/10.1016/j.
tailored to the specific needs of each patient. accpm.2018.02.019
7. Oliveira MB, Machado HS. Journal of Anesthesia
The objectives of diabetes perioperative care are to & Clinical Perioperative Management of Patients
reduce morbidity and mortality. In order to obtain with Down Syndrome : A Review. 2019;9(4):1–14.
such, in this scenario, the focus is on using various 8. Levy N, Penfold N, Mythen M. Perioperative
pharmaceutical therapy to reduce hyperglycemia and management of diabetes and the emerging role
hypoglycemia. Despite the lack of consensus and strong of anaesthetists as perioperative physicians. Br J
studies, a number of perioperative diabetes treatment Anaesth [Internet]. 2016 Apr 1 [cited 2021 Aug
suggestions can be made, and these have been covered. 5];116(4):443–7. Available from: http://www.
More study is needed to back up a number of our bjanaesthesia.org/article/S0007091217303963/
empirical findings. fulltext
9. Likhvantsev V V., Zabelina TS, Grebenchikov OA,
CONCLUSION Shapkin MA. Perioperative Management of Patients
With Diabetes Mellitus. Anesteziol Reanimatol.
DM is a metabolic illness that frequently affects 2016;61(4):290–3.
surgical patients and requires a specific treatment 10. Underwood P, Seiden J, Carbone K, Chamarthi
plan. Patients with diabetes who are going to have B, Turchin A, Bader A, et al. Early identification
surgery need perioperative treatment that focuses on of individuals with poorly controlled diabetes
improving BG control and paying attention to any undergoing elective surgery: Improving A1C
existing comorbidities so that complications during testing in the preoperative period. Endocr Pract.
or after surgery can be avoided. Hyperglycemia can 2015;21(3):231–6.
be avoided, which reduces postoperative morbidity, 11. Udovcic M, Castro JC, Apsey HA, Stearns JD,
mortality, and infection. Insulin therapy, insulin sliding Schlinkert RT, Cook CB. Guidelines to improve
scales, and insulin infusion are all options for preventing perioperative management of diabetes mellitus:
hyperglycemia. Increased blood sugar levels in diabetic Assessment of the impact of change across
and nondiabetic patients are now associated to an time. Endocr Pract [Internet]. 2015 Sep 1 [cited
increased risk of perioperative complications. Treatment 2021 Aug 5];21(9):1026–34. Available from:
with insulin before and after surgery has been shown http://www.endocrinepractice.org/article/
to improve clinical results. Patient features and surgical S1530891X20357293/fulltext
case concerns are taken into account when determining 12. Shah M, Apsey HA, Stearns JD, Schlinkert RT,
whether to use subcutaneous insulin or insulin infusion. Seifert KM, Cook CB. Guidelines to improve
perioperative management of diabetes mellitus: an
REFERENCES example of a successful quality initiative. Diabetes
Manag. 2014;4(4):327–37.
1. Palermo NE, Garg R. Perioperative Management of 13. Apsey HA, Coan KE, Castro JC, Jameson KA,
Diabetes Mellitus: Novel Approaches. Curr Diab Schlinkert RT, Cook CB. Overcoming clinical
Rep. 2019;19(4):1–7. inertia in the management of postoperative patients
2. Sudhakaran S, Surani SR. Guidelines for with diabetes. Endocr Pract. 2014;20(4):320–8.
Perioperative Management of the Diabetic Patient. 14. Umpierrez GE, Hellman R, Korytkowski MT, al.
Surg Res Pract. 2015;2015. et. Management of hyperglycemia in hospitalized
3. McAnulty GR, Robertshaw HJ, Hall GM. patients in non-critical care setting: an Endocrine
Anaesthetic management of patients with diabetes Society clinical practice guideline. J Clin Endocrinol
mellitus. Br J Anaesth. 2000;85(1):80–90. Metab. 2012;97:16–38.

299 Mal J Med Health Sci 18(SUPP3):294-302, Feb 2022

 Malaysian Journal of Medicine and Health Sciences (eISSN 2636-9346)

15. Boyle ME, Seifert KM, Beer KA, al. et. Insulin pump 29. Coan KE, Schlinkert AB, Beck BR, al. et. Clinical
therapy in the perioperative period: a review of care inertia during postoperative management
after implementation of institutional guidelines. J of diabetes mellitus: relationship between
Diabetes Sci Technol. 2012;6:1016–21. hyperglycemia and insulin therapy intensification.
16. Leibowitz G, Raizman E, Brezis M, Glaser B, Raz J Diabetes Sci Technol. 2013;7:880–7.
I, Shapira O. Effects of moderate intensity glycemic 30. Corriere MD, Minang LB, Sisson SD, Brancati FL,
control after cardiac surgery. Ann Thorac Surg. Kalyani RR. The use of clinical guidelines highlights
2010;90:1825–32. ongoing educational gaps in physicians’ knowledge
17. Sato H, Carvalho G, Sato T, Lattermann R, and decision making related to diabetes. BMC Med
Matsukawa T, Schricker T. The association of Educ. 2014;14:1–7.
preoperative glycemic control, intraoperative 31. Mechanick JI, Pessah-Pollack R, Camacho P,
insulin sensitivity, and outcomes after cardiac Correa R, Figaro MK, Garber JR, et al. American
surgery. J Clin Endocrinol Metab. 2010;95:4338– Association of Clinical Endocrinologists and
44. American College of Endocrinology Protocol
18. Hanazaki K, Maeda H, Okabayashi T. Relationship for Standardized Production of Clinical Practice
between perioperative glycemic control and Guidelines, Algorithms, and Checklists – 2017
postoperative infections. World J Gastroenterol. Update. Endocr Pract [Internet]. 2017 Aug 1
2009;15:4122–5. [cited 2021 Aug 5];23(8):1006–21. Available
19. Park C, Hsu C, Neelakanta G, al. et. Severe from: http://www.endocrinepractice.org/article/
intraoperative hyperglycemia is independently S1530891X20358523/fulltext
associated with surgical site infection after liver 32. Han H, Chao H, Guerra A, al. et. Evolution of the
transplantation. Transplantation. 2009;15:1031–6. American College of Cardiology/American Heart
20. Cheisson G, Jacqueminet S, Cosson E, Ichai Association clinical guidelines. J Am Coll Cardiol.
C, Leguerrier AM, Nicolescu-Catargi B, et al. 2015;65:2726–34.
Perioperative management of adult diabetic 33. Echouffo-Tcheugui JB, Xu H, DeVore AD, al.
patients. Review of hyperglycaemia: definitions et. Temporal trends and factors associated with
and pathophysiology. Anaesth Crit Care Pain Med. diabetes mellitus among patients hospitalized
2018 Jun 1;37:S5–8. with heart failure: findings from Get With The
21. Kayes N, Prodhan NMNK, Malik RH. Review Guidelines-Heart Failure registry. Am Hear J.
Article Perioperative Management of Diabetes : A 2016;182:9–20.
Review. Delta Med Col J. 2014;2(2):71–6. 34. Garvey WT, Mechanick JI, Brett EM, al. et.
22. Martin LD, Hoagland MA, Rhodes ET, Wolfsdorf American Association of Clinical Endocrinologists
JI, Hamrick JL. Perioperative management of and American College of Endocrinology
pediatric patients with type 1 diabetes mellitus, comprehensive clinical practice guidelines for
updated recommendations for anesthesiologists. medical care of patients with obesity. Endocr Pr.
Anesth Analg. 2020;130(4):821–7. 2016;22:1–203.
23. Kuzulugil D, Papeix G, Luu J, Kerridge RK. 35. Ayari Y, Taktak T, Boussaffa H, Ghorbel Z, Zehani A,
Recent advances in diabetes treatments and their Sellami A, et al. Retroperitoneal extra-adrenal non-
perioperative implications. Curr Opin Anaesthesiol. Hodgkin lymphoma: An uncommon presentation.
2019;32(3):398–404. Urol Case Reports. 2019 Mar 1;23:34–6.
24. Muermann MM, Retief PJ. Perioperative 36. Albrecht E, Bayon V, Hirotsu C, Heinzer R. Impact
management of patients with diabetes mellitus: of short-acting vs. standard anaesthetic agents
ketone screening. Can J Anesth. 2021;68(6):923–4. on obstructive sleep apnoea: a randomised,
25. Coan KE, Schlinkert AB, Beck BR, al. et. controlled, triple-blind trial. Anaesthesia. 2021 Jan
Perioperative management of patients with 1;76(1):45–53.
diabetes undergoing ambulatory elective surgery. 37. Thiruvenkatarajan V, Wood R, Watts R, Currie J,
J Diabetes Sci Technol. 2013;7:983–9. Wahba M, Van Wijk RM. The intraoperative use of
26. Association AD. Standards of medical care in non-opioid adjuvant analgesic agents: A survey of
diabetes: 2014. Diabetes Care. 2014;37:S14–80. anaesthetists in Australia and New Zealand. BMC
27. Dhatariya K. Comment on Underwood et al.: Anesthesiol. 2019 Oct 21;19(1).
Preoperative A1C and clinical outcomes in patients 38. Gao PF, Lin JY, Wang S, Zhang YF, Wang GQ, Xu Q,
with diabetes undergoing major noncardiac et al. Antinociceptive effects of magnesium sulfate
surgical procedures. Vol. 37, Diabetes Care. 2014. for monitored anesthesia care during hysteroscopy:
p. 611–6. A randomized controlled study. BMC Anesthesiol.
28. Nath SS, Das PK. A Commentary: Effects on 2020 Sep 21;20(1).
glargine insulin on glycemic control in patients 39. Bartholmes F, Malewicz NM, Ebel M, Zahn PK,
with diabetes mellitus type II undergoing off-pump Meyer-Frießem CH. Pupillometric monitoring of
coronary artery bypass graft. Ann Card Anaesth. nociception in cardiac anesthesia. Dtsch Arztebl
2018;21(2):173–4. Int. 2020;117:833–40.

Mal J Med Health Sci 18(SUPP3):294-302, Feb 2022 300

Malaysian Journal of Medicine and Health Sciences (eISSN 2636-9346)

40. Elhawary H, Abdelhamid K, Meng F, Janis JE. procedures : improving standards Summary.
Erector Spinae Plane Block Decreases Pain and Jt Br Diabetes Soc Inpatient Care [Internet].
Opioid Consumption in Breast Surgery: Systematic 2011;(April):40. Available from: www.diabetes.
Review. Plast Reconstr Surg - Glob Open. nhs.uk
2019;7(11). 54. du Toit L, Biesman-Simons T, Levy N, Dave JA.
41. Salam R. Perioperative management of diabetes A practical approach to managing diabetes in
mellitus. JMS - J Med Soc. 2015;28(1):4–8. the perioperative period. South African Med J.
42. Hamlin NP. Perioperative diabetes management. 2018;108(5):369–75.
Perioper Med Consult Handb. 2013;8:143–51. 55. Garg R, Hurwitz S, Turchin A, al. et. Hypoglycemia,
43. Fernández-Ginés FD, Cortiñas-Sáenz M, Agudo- with or without insulin therapy, is associated with
Ponce D, Navajas-Gómez de Aranda A, Morales- increased mortality among hospitalized patients.
Molina JA, Fernández-Sánchez C, et al. Pain Diabetes Care. 2013;36:1107–10.
reduction of topical sevoflurane vs intravenous 56. Broekhuizen H, Ijzerman MJ, Hauber AB, al.
opioids in pressure ulcers. Int Wound J. 2020 Feb et. Weighing clinical evidence using patient
1;17(1):83–90. preferences: an application of probabilistic multi-
44. Tong Y, Fernandez L, Bendo JA, Spivak JM. criteria decision analysis. Pharmacoeconomics.
Enhanced recovery after surgery trends in adult 2017;35:259–69.
spine surgery: A systematic review. Int J Spine Surg. 57. Hlatky MA. Considering cost-effectiveness in
2020;14(4):623–40. cardiology clinical guidelines: progress and
45. Jin S, Liang DD, Chen C, Zhang M, Wang J. prospects. Value Heal. 2016;19:516–9.
Dexmedetomidine prevent postoperative nausea 58. Anaesthetists RC of. Guidelines for the provision of
and vomiting on patients during general anesthesia: Anaesthetic services (GPAS). 2015.
A PRISMA-compliant meta analysis of randomized 59. Han H, Kang S. Relations between long-term
controlled trials. Med (United States). 2017;96(1). glycemic control and postoperative wound
46. Edelson GW, Fachnie JD, Whitehouse FW. and infectious complications after total knee
Perioperative management of diabetes. Henry Ford arthroplasty in type 2 diabetics. Clin Orthop Surg.
Hosp Med J. 1990;38(4):262–5. 2013;5:118–23.
47. Elgendy H, Youssef T, Banjar A, Elmorsy S. 60. Camacho PM, Petak SM, Binkley N, al. et.
Decreased Analgesic Requirements in Super American Association of Clinical Endocrinologists
Morbidly Versus Morbidly Obese Patients and American College of Endocrinology clinical
Undergoing Laparoscopic Sleeve Gastrectomy. practice guidelines for the diagnosis and treatment
Obes Surg. 2020 Jul 1;30(7):2715–22. of postmenopausal osteoporosis - 2016. Endocr Pr.
48. Kaye AD, Chernobylsky DJ, Thakur P, Siddaiah 2016;22:1–42.
H, Kaye RJ, Eng LK, et al. Dexmedetomidine in 61. Guallar E, Laine C. Controversy over clinical
Enhanced Recovery After Surgery (ERAS) Protocols guidelines: listen to the evidence, not the noise.
for Postoperative Pain. Curr Pain Headache Rep. Ann Int Med. 2014;160:361–2.
2020 May 1;24(5). 62. Moreno EM, Moriana JA. User involvement in the
49. Dhatariya K, Nunney I, Higgins K, Sampson M, implementation of clinical guidelines for common
Iceton G. A national survey of the management of mental health disorders: a review and compilation
diabetic ketoacidosis in the UK in 2014. Diabet of strategies and resources. Heal Res Policy Syst.
Med. 2016;33:252–60. 2016;14:61.
50. Stryker L, Abdel M, Morrey M, Morrow M, Kor D, 63. Austad B, Hetlevik I, Mjølstad BP, Helvik AS.
Morrey B. Elevated postoperative blood glucose Applying clinical guidelines in general practice: a
and preoperative hemoglobin A1C are associated qualitative study of potential complications. BMC
with increased wound complications following Fam Pr. 2016;17:92.
total joint arthroplasty. J Bone Jt Surg. 2013;95:808– 64. Handelsman Y, Bloomgarden ZT, Grunberger
14. G, al. et. American Association of Clinical
51. García-Sáez G, Rigla M, Martínez-Sarriegui I, Endocrinologists and American College of
al. et. Patient-oriented computerized clinical Endocrinology - clinical practice guidelines for
guidelines for mobile decision support in gestational developing a diabetes mellitus comprehensive
diabetes. J Diab Sci Technol. 2014;8:238–46. care plan - 2015. Endocr Pr. 2015;21:1–87.
52. Underwood P, Askari R, Hurwitz S, Chamarthi B, 65. Berthoud V, Nguyen M, Appriou A, Ellouze O,
Garg R. Preoperative A1C and clinical outcomes Radhouani M, Constandache T, et al. Pupillometry
in patients with diabetes undergoing major pain index decreases intraoperative sufentanyl
noncardiac surgical procedures. Diabetes Care. administration in cardiac surgery: a prospective
2014;37:611–6. randomized study. Sci Rep. 2020 Dec 1;10(1).
53. Dhatairiya K, Flanagan D, Hilton L, Kilvery A, 66. Kang R, Jeong JS, Ko JS, Lee SY, Lee JH, Choi SJ,
Levy N, Rayman G, et al. Management of adults et al. Intraoperative dexmedetomidine attenuates
with diabetes undergoing surgery and elective norepinephrine levels in patients undergoing

301 Mal J Med Health Sci 18(SUPP3):294-302, Feb 2022

 Malaysian Journal of Medicine and Health Sciences (eISSN 2636-9346)

transsphenoidal surgery: A randomized, placebo- Superimposed on Dementia in Perioperative

controlled trial. BMC Anesthesiol. 2020 May Period and Intensive Care. J Clin Med. 2020 Oct
2;20(1). 13;9(10):3279.
67. Krzych ŁJ, Rachfalska N, Putowski Z. Delirium

Mal J Med Health Sci 18(SUPP3):294-302, Feb 2022 302