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Perioperative Management of Diabetes - Article
ABSTRACT: Maintaining glycemic and metabolic control is difficult in diabetic patients who are undergoing surgery. The preoperative evaluation of all patients with diabetes should include careful screening for asymptomatic cardiac or renal disease. Frequent self-monitoring of glucose levels is important in the week before surgery so that insulin regimens can be adjusted as needed. Oral agents and long-acting insulin are usually discontinued before surgery, although the newer long-acting insulin analog glargine may be appropriately administered for basal insulin coverage throughout the surgical period. The usual regimen of sliding scale subcutaneous insulin for perioperative glycemic control may be a less preferable method because it can have unreliable absorption and lead to erratic blood glucose levels. Intravenous insulin infusion offers advantages because of the more predictable absorption rates and ability to rapidly titrate insulin delivery up or down to maintain proper glycemic control. Insulin is typically infused at 1 to 2 U per hour and adjusted according to the results of frequent blood glucose checks. A separate infusion of dextrose prevents hypoglycemia. Potassium is usually added to the dextrose infusion at 10 to 20 mEq per L in patients with normal renal function and normal preoperative serum potassium levels. Frequent monitoring of electrolytes and acid-base status is important during the perioperative period, especially in patients with type 1 diabetes because ketoacidosis can develop at modest levels of hyperglycemia.
ABSTRACT: Approximately 20 to 40 percent of patients at high risk of cardiac-related morbidity develop myocardial ischemia perioperatively. The preferred approach to diagnostic evaluation depends on the interactions of patient-specific risk factors, surgery-specific risk factors, and exercise capacity. Stress testing should be reserved for patients at moderate to high risk undergoing moderate- or high-risk surgery and those who have poor exercise capacity. Further cardiovascular studies should be limited to patients who are at high risk, have poor exercise tolerance, or have known poor ventricular function. Medical therapy using beta blockers, statins, and alpha agonists may be effective in high-risk patients. The evidence appears to be the strongest for beta blockers, especially in high-risk patients with proven ischemia on stress testing who are undergoing vascular surgery. Many questions remain unanswered, including the optimal role of statins and alpha agonists, whether or not these therapies are as effective in patients with subclinical coronary artery disease or left ventricular dysfunction, and the optimal timing and dosing regimens of these medications.
Updated Guidelines for Perioperative Cardiovascular Evaluation for Noncardiac Surgery - Practice Guidelines
A Common Sense Approach to Perioperative Evaluation - Editorials
Perioperative Cardiac Risk Reduction - Article
ABSTRACT: Cardiovascular complications are the most common cause of perioperative morbidity and mortality. Noninvasive stress testing is rarely helpful in assessing risk, and for most patients there is no evidence that coronary revascularization provides more protection against perioperative cardiovascular events than optimal medical management. Patients likely to benefit from perioperative beta blockade include those with stable coronary artery disease and multiple cardiac risk factors. Perioperative beta blockers should be initiated weeks before surgery and titrated to heart rate and blood pressure targets. The balance of benefits and harms of perioperative beta-blocker therapy is much less favorable in patients with limited cardiac risk factors and when initiated in the acute preoperative period. Perioperative statin therapy is recommended for all patients undergoing vascular surgery. When prescribed for the secondary prevention of cardiovascular disease, aspirin should be continued in the perioperative period.