By Olivia Marsh MSN RN
With 10.5% of the US population or 34.2 million people of all ages reported as having diabetes by the National Diabetes Statistics Report of 2020 (p. 2), it is highly likely that perioperative nurses will care for a patient who also has diabetes. The American Diabetes Association (ADA) acknowledges the lack of evidence-based information available for the perioperative setting and provides some recommendations (American Diabetes Association, 2021, S216). Major goals for diabetes management in the perioperative setting focus on preventing hypoglycemia and maintaining appropriate glycemic control to decrease the associated long-term risks of hyperglycemia. This is a disease process that requires planning, focused assessments and interventions, and often interdepartmental support to meet all the needs of surgical patients with diabetes. The complexity of diabetes, both insulin dependent and non-insulin dependent, during surgery can not be completely discussed in this article. Instead, sharing nursing implications that lead to ideas for practice changes are presented in a three-part presentation for the perioperative nurse to take back and incorporate into the clinical area.
Glycemic parameters should be standard for education and clinical implications. Hypoglycemia level 1 is referenced as 54 - 70 mg/dL (3.0 - 3.9 mmol/L) while level 2 is a blood glucose level less than 54 mg/dL (3.0mmo/L) by the ADA (2021, p S214). Hypoglycemia level 2 and lower is the threshold for neuroglycopenic symptoms (ADA, 2021, p S214) and is an emergency that needs to be dealt with immediately. Standard order sets for the treatment of symptomatic hypoglycemia with intravenous (IV) dextrose should be available for immediate treatment. These order sets should reference a large gauge peripheral IV with proximal placement, ideally, antecubital. “Hyperglycemia in hospitalized patients is defined as blood glucose levels greater than 140 mg/dL (7.8 mmol/L)” (ADA, 2021, p S214). Those parameters should be observed on arrival to PreOp, on arrival to PACU, and range from hourly to every 2 hours while in PACU (Duggan et al., 2017, p 555). Providers should have standard treatment orders for both hyperglycemia and hypoglycemia available for diabetic patients upon arrival to the preoperative setting.
The perianesthesia nurse usually has their first point of contact with the diabetic patient during the Pre-Admission Testing phone call. This is when prescribed medication use is reviewed and disease processes are considered, along with previous anesthesia history. Individual plans to stop or adjust anti-diabetic medications, in addition to NPO guidelines, should be collaborated on together with clinicians and the patient (American Diabetes Association, 2021, S216). Clear liquids, especially carbohydrate-rich drinks are recommended up to 2 hours before surgery by Enhanced Recovery After Surgery (ERAS) programs. The purpose is to promote gut motility and reduce insulin resistance after surgery (Engelman et al., 2019). The ADA recommendations of 2021 (ADA, 2021, S216) suggests that hospitalized patients with diabetes should have consults by trained Certified Diabetes Care and Educations Specialists (CDCES) as part of their plan of care. In addition, the ADA recommends that Metformin be withheld the day of surgery and SGLT2 inhibitors be stopped 3-4 days prior to surgery. Also, administer a half dose of NPH and reduce basil insulin from a pump by 75–80% of the usual dose. Creating an operating practice that contains this information will help perioperative nurses to better prepare patients with diabetes for their surgical encounter. In Part 2 we will discuss implications of Preoperative care when a patient arrives for surgery and intraoperative care. Stay tuned!
References
American Diabetes Association (2021, January). Diabetes care in the hospital: Standards of medical care in diabetes-2021. Diabetes Care, 44 (Supplement 1) S211-S220. https://doi.org/10.2337/dc21-S015
Duggan, E.W., Carlson, K., & Umpierrez, G.E. (2017, March). Perioperative hyperglycemia management: An update. Anesthesiology, Vol. 126, 546-560. https://doi.org/10.1097/ALN.0000000000001515
Engelman D.T., Ben Ali W., & Williams J.B., (2019) Guidelines for perioperative care in cardiac surgery: Enhanced recovery after surgery society recommendations. JAMA Surg. 154(8):755–766. doi:10.1001/jamasurg.2019.1153
Haire-Joshu, D., (1996). Management of diabetes mellitus: Perspectives of care across the life span. 2nd ed. Mosby
National diabetes statistics report 2020: Estimates of diabetes and its burden in the United States (2020). Retrieved from https://www.diabetesresearch.org/file/national-diabetes-statistics-report-2020.pdf