Glycemic control is a crucial component of type 2 diabetes management. Surgery may impair normal glucose metabolism and during the recovery period. Furthermore, diabetic patients are at a higher risk of postoperative complications such as surgical site infections and delayed wound healing (Akiboye & Rayman, 2017). Therefore, it is important to ensure proper glycemic control in the course of the perioperative period. This paper reviews the literature on the management of blood sugar levels in patients with type 2 diabetes before and after surgery. The PubMed and Google Scholar databases were searched using the key terms type 2 diabetes, blood sugar control, and surgery. The search was narrowed down to articles published within the last five years. A total of ten relevant articles were selected and evaluated.
The recommended first-line treatment for type 2 diabetes is metformin and combination therapy (American Diabetes Association [ADA], 2020). Oral agents such as glucagon-like peptide 1 receptor agonists are preferred to insulin if the first treatment is ineffective. Therefore, insulin should be used as a last resort when all other options do not yield the glycemic targets. Nevertheless, different patient groups have been reported to have varying patterns of insulin use (Kong et al., 2020). However, additional precautions are needed during the perioperative period. First, preoperative assessment of blood sugar levels is the first step towards the proper management of glucose levels. Patients with type 2 diabetes should be assessed a few days before the scheduled surgery to establish other parameters such as ketones and electrolyte standing in addition to glycemic control (Jefferies et al., 2018). Akiboye and Rayman (2017) recommend the treatment of hyperglycemia during the perioperative period. The normal target is fasting blood glucose levels of 5.0 to 8.0 mmol/L. Ferrera et al. (2019) demonstrated that subjecting patients to a carbohydrate reduced hospital diet containing 135 grams of carbohydrates per day resulted in improved glycemic control post-surgery.
Patients on insulin treatment should continue with the treatment at a reduced dose to prevent ketoacidosis. Their blood sugar levels should be monitored every hour before, during, and after surgery to identify and address hypo or hyperglycemia (Ferrera et al., 2019). The type of insulin can also influence blood glucose outcomes. Pasquel et al. (2020) observed that treating hospitalized patients with glargine U300 and glargine U100 produced comparable glycemic control. However, glargine U100 is linked to a lower incidence of hypoglycemia and can be considered in the prevention of hypoglycemia.
An intravenous infusion should be considered for surgical procedures lasting 2 hours or less. For longer surgeries, dextrose should be included in the infusion and adjusted appropriately to ensure that the blood glucose level is between 5 and 10 mmol/L. The normal diabetes regimen should be continued as soon as the patient resumes oral nutrition. However, higher doses of insulin may be required immediately after surgery because of stress, pain, and inactivity. Therefore, blood glucose levels should be checked frequently within the first two days following surgery. Statins can minimize the risk of cardiovascular events in diabetic patients undergoing hemodialysis. Genser, Wanner, and März (2020) have developed a score that can be used to forecast the precise effects of statins in diabetic patients undergoing hemodialysis, thereby minimizing their adverse effects in this patient group.
Dietary interventions can also be used to manage blood glucose levels for hospitalized patients with type 2 diabetes post-surgery. Skalkos, Moschonis, Thomas, McMillan, and Kouris-Blazos (2020) established that taking lupin biscuits as a mid-meal snack resulted in a significant reduction in postprandial glucose after dinner. In an outpatient setting, the administration of sodium-glucose cotransporter 2 (SGLT2) inhibitors, which work by reducing the kidney retention of glucose, can also be used for glycemic control (Mazer et al., 2020). Surgical interventions can also aid glycemic control. For instance, van Baar et al. (2020) observed that duodenal mucosal resurfacing can enhance glycemic control in people with type 2 diabetes notwithstanding their body mass index.
References
Akiboye, F., & Rayman, G. (2017). Management of hyperglycemia and diabetes in orthopedic surgery. Current Diabetes Reports, 17(2), 1-11.
American Diabetes Association. (2020). 9. Pharmacologic approaches to glycemic treatment: Standards of medical care in diabetes-2020. Diabetes Care, 43(Suppl 1), S98-S110.
Ferrera, H. K., Jones, T. E., Schudrowitz, N. J., Collins, J. E., Lichstein, P. M., Shaner, J. L., & Fitz, W. (2019). Perioperative dietary restriction of carbohydrates in the management of blood glucose levels in patients undergoing total knee replacement. The Journal of Arthroplasty, 34(6), 1105-1109.
Genser, B., Wanner, C., & März, W. (2020). A scoring system for predicting individual treatment effects of statins in type 2 diabetes patients on haemodialysis. European Journal of Preventive Cardiology, 2047487320905721.
Jefferies, C., Rhodes, E., Rachmiel, M., Agwu, J. C., Kapellen, T., Abdulla, M. A., & Hofer, S. E. (2018). ISPAD Clinical Practice Consensus Guidelines 2018: Management of children and adolescents with diabetes requiring surgery. Pediatric Diabetes, 19(Suppl 27), 227-326.
Kong, A. P., Lew, T., Lau, E. S., Lim, L. L., Kesavadev, J., Jia, W., & Yoon, K. H. (2020). Real‐world data reveal unmet clinical needs in insulin treatment in Asian people with type 2 diabetes: The Joint Asia Diabetes Evaluation (JADE) Register. Diabetes, Obesity and Metabolism, 22(4), 669-679.
Mazer, C. D., Arnaout, A., Connelly, K. A., Gilbert, J. D., Glazer, S. A., Verma, S., & Goldenberg, R. M. (2020). Sodium-glucose cotransporter 2 inhibitors and type 2 diabetes. Current Opinion in Cardiology, 35(2), 178-186.
Pasquel, F. J., Lansang, M. C., Khowaja, A., Urrutia, M. A., Cardona, S., Albury, B., & Vellanki, P. (2020). A randomized controlled trial comparing glargine U300 and glargine U100 for the inpatient management of medicine and surgery patients with type 2 diabetes: Glargine U300 hospital trial. Diabetes Care, 43(6), 1242-1248.
Skalkos, S., Moschonis, G., Thomas, C. J., McMillan, J., & Kouris-Blazos, A. (2020). Effect of Lupin-Enriched Biscuits as Substitute Mid-Meal Snacks on Post-Prandial Interstitial Glucose Excursions in Post-Surgical Hospital Patients with Type 2 Diabetes. Nutrients, 12(5), 1-15.
van Baar, A. C., Holleman, F., Crenier, L., Haidry, R., Magee, C., Hopkins, D., & Mertens, A. (2020). Endoscopic duodenal mucosal resurfacing for the treatment of type 2 diabetes mellitus: One year results from the first international, open-label, prospective, multicentre study. Gut, 69(2), 295-303.