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INTRODUCTION

According to the 2020 National Diabetes Statistics Report, approximately 34 million Americans, 13% of the adult population, have diabetes mellitus (DM). Only 27 million of those patients know they have DM. Adults 65 years old and older make up almost half of the DM cases, and adults 46–64 years old constitute the other half. Moreover, we estimate that another 88 million Americans have prediabetes. You will encounter perioperative hyperglycemia. Twenty to forty percent of patients undergoing general surgery have perioperative hyperglycemia while 80% of patients experience hyperglycemia after cardiac surgery.1 Up to 30% of patients with postoperative hyperglycemia will have no prior history of DM. Their hyperglycemia is due to undiagnosed DM or the effects of the counter regulatory hormones secreted during surgery. The stress of surgery induces the secretion of hormones like catecholamines, cortisol, glucagon, and growth hormone. These hormones induce the release of inflammatory cytokines and overall lead to a cascade of effects that result in a state of relative insulin resistance. This chapter will review preoperative evaluation and perioperative management of the patients with DM undergoing noncardiac surgery.

HOW TO DIAGNOSE DIABETES

Diabetes is generally diagnosed using glycosylated hemoglobin (HbA1c), fasting plasma glucose (FPG), or classic DM symptoms with the values listed in Table 18-1.2 HbA1c reflects the average blood sugar over the last 3 months but cannot differentiate whether the glucose control has improved, worsened, fluctuated, or stayed the same over that timeframe. Please note that HbA1c can result in false negatives in patients with red blood cells that turn over faster than every 90 days. This includes patients with hemoglobinopathies like sickle cell disease and patients with G6PD deficiency. HIV patients, hemodialysis patients, patients who have had a recent blood transfusion, or patients who receive erythropoietin therapy can also have misleading results. In these patient populations, use an alternative test to diagnose DM. Patients who have not fasted for 8 hours but have a plasma glucose of < 100 mg/dl do not have DM. DM can be diagnosed with a 2-hour oral glucose tolerance test, but it is generally reserved for pregnant patients under evaluation for gestational DM.

TABLE 18-1DM Diagnosis

PREOPERATIVE EVALUATION HISTORY

Caring for patients with diabetes requires performing an appropriate history and physical (Table 18-2). The history should focus on disease-specific information like the duration of the disease, the treatment, adverse consequences of the medications, including hypoglycemia, and the complications of the disease process, including target organ damage. The history should also include surgery-specific details ...

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