Perioperative management of diabetic patients

Diabetes mellitus is the most common metabolic disease. New classifications have recently been proposed by the American Diabetes Association (ADA) and the World Health Organization (WHO). Type 1 (formerly insulin-dependent diabetes mellitus IDDM) is immune-mediated and leads to absolute insulin deficiency. Type 2 diabetes (formerly non-insulin-dependent diabetes mellitus [NIDDM]) is a disease of adult onset and is associated with insulin resistance. Type 3 corresponds to a wide range of specific types of diabetes, including various genetic defects of beta-cell function and insulin action, diseases of exocrine pancreas, endocrinopathies, and drug-induced diabetes. Type 4 is gestational diabetes (Table 1). Diabetics undergoing surgery have increased mortality, and type 1 diabetics are particularly at risk of postoperative complications. Wound complications are increased in diabetics, and healing is severely impaired when glycemic control is poor. However, with the use of modern management plans, the major outcome measures of surgery are comparable in diabetic and nondiabetic patients. Successful management of surgery in diabetic patients requires simple and safe protocols, which are fully understood by all staff and a close liaison among the surgeons, diabetes care team, and anesthetists. There is no consensus on the optimal metabolic management of the diabetic patient during surgery. Several surveys have highlighted the inconsistency with which surgical problems are managed in diabetic patients. The aim of this article is to provide protocols to achieve sensible and practical glycemic control in diabetic patients undergoing surgery.