Evaluation and perioperative management of patients with diabetes mellitus. A challenge for the anesthesiologist

João Paulo Jordão Pontes; Florentino Fernandes Mendes; Mateus Meira Vasconcelos; Nubia Rodrigues Batista

doi:10.1016/j.bjane.2017.06.002

Review Article

Evaluation and perioperative management of patients with diabetes mellitus. A challenge for the anesthesiologist

Avaliação e manejo perioperatório de pacientes com diabetes melito. Um desafio para o anestesiologista

João Paulo Jordão Pontes; Florentino Fernandes Mendes; Mateus Meira Vasconcelos; Nubia Rodrigues Batista

http://dx.doi.org/10.1016/j.bjane.2017.06.002 Braz J Anesthesiol, vol.68, n1, p.75-86, 2018

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Abstract

Abstract Diabetes mellitus (DM) is characterized by alteration in carbohydrate metabolism, leading to hyperglycemia and increased perioperative morbidity and mortality. It evolves with diverse and progressive physiological changes, and the anesthetic management requires attention regarding this disease interference in multiple organ systems and their respective complications. Patient's history, physical examination, and complementary exams are important in the preoperative management, particularly glycosylated hemoglobin (HbA1c), which has a strong predictive value for complications associated with diabetes. The goal of surgical planning is to reduce the fasting time and maintain the patient's routine. Patients with Type 1 DM must receive insulin (even during the preoperative fast) to meet the basal physiological demands and avoid ketoacidosis. Whereas patients with Type 2 DM treated with multiple injectable and/or oral drugs are susceptible to develop a hyperglycemic hyperosmolar state (HHS). Therefore, the management of hypoglycemic agents and different types of insulin is fundamental, as well as determining the surgical schedule and, consequently, the number of lost meals for dose adjustment and drug suspension. Current evidence suggests the safe target to maintain glycemic control in surgical patients, but does not conclude whether it should be obtained with either moderate or severe glycemic control.

Keywords

Diabetes mellitus, Anesthesia, Perioperative care, Hypoglycemic agents, Insulin, Glycosylated hemoglobin

Resumo

Resumo O diabetes melito (DM) é caracterizado por alteração no metabolismo de carboidratos que leva à hiperglicemia e ao aumento da morbimortalidade perioperatória. Cursa com alterações fisiológicas diversas e progressivas e, para o manejo anestésico, deve-se atentar para a interferência dessa doença nos múltiplos sistemas orgânicos e suas respectivas complicações. Anamnese, exame físico e exames complementares são importantes no manejo pré-operatório, com destaque para a hemoglobina glicosilada (HbA1c), que tem forte valor preditivo para complicações associadas ao diabetes. O planejamento cirúrgico tem como objetivos a redução do tempo de jejum e a manutenção da rotina do paciente. Pacientes portadores de DM Tipo 1 precisam receber, mesmo em jejum perioperatório, insulina para suprir as demandas fisiológicas basais e evitar cetoacidose. Já os pacientes portadores de DM Tipo 2, tratados com múltiplos fármacos injetáveis e/ou orais, são suscetíveis ao desenvolvimento de um estado hiperosmolar hiperglicêmico (EHH). Assim, o manejo dos hipoglicemiantes e dos diferentes tipos de insulina é fundamental, além da determinação do horário cirúrgico e, consequentemente, do número de refeições perdidas para adequação de doses ou suspensão dos medicamentos. As evidências atuais sugerem o alvo de manutenção da glicemia seguro para os pacientes cirúrgicos, sem concluir se deve ser obtido com controle glicêmico intensivo ou moderado.

Palavras-chave

Diabetes melito, Anestesia, Cuidados perioperatórios, Hipoglicemiantes, Insulina, Hemoglobina glicosilada

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Evaluation and perioperative management of patients with diabetes mellitus. A challenge for the anesthesiologist

Avaliação e manejo perioperatório de pacientes com diabetes melito. Um desafio para o anestesiologista

João Paulo Jordão Pontes; Florentino Fernandes Mendes; Mateus Meira Vasconcelos; Nubia Rodrigues Batista

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