Diabetes mellitus - Revision history

Bsumida1 at 14:23, 3 August 2022

2022-08-03T14:23:54Z

← Older revision		Revision as of 07:23, 3 August 2022
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	Institutional practices may vary, however the general principle is to perform close monitoring and maintain euglycemia. Stanford intraoperative glycemic care guidelines recommend targeting a blood glucose of 140-180 during surgery<ref name=":2">{{Cite web\|title=Intraoperative Glycemic Care Guidelines\|url=https://ether.stanford.edu/policies/Intraoperative%20Glycemic%20Care%20Guidelines%20and%20appendix.pdf\|url-status=live}}</ref>. An interval of q2h is appropriate if the patient's blood glucose remains within this range. Sugars between 70-140 warrant closer q1h monitoring, and any sugar below 70 in most adult patients necessitates treatment with a dextrose bolus (e.g. 12.5 g of D50) with subsequent q15 min glucose checks.		Institutional practices may vary, however the general principle is to perform close monitoring and maintain euglycemia. Stanford intraoperative glycemic care guidelines recommend targeting a blood glucose of 140-180 during surgery<ref name=":2">{{Cite web\|title=Intraoperative Glycemic Care Guidelines\|url=https://ether.stanford.edu/policies/Intraoperative%20Glycemic%20Care%20Guidelines%20and%20appendix.pdf\|url-status=live}}</ref>. An interval of q2h is appropriate if the patient's blood glucose remains within this range. Sugars between 70-140 warrant closer q1h monitoring, and any sugar below 70 in most adult patients necessitates treatment with a dextrose bolus (e.g. 12.5 g of D50) with subsequent q15 min glucose checks.

	For patients with hyperglycemia >180, the duration of surgery and level of critical illness can guide whether intermittent subcutaneous insulin vs continuous insulin infusion is appropriate for intraoperative management. Subcutaneous insulin (e.g. Humalog/Lispro) is delivered every 2-3 hours based on a sliding scale (cannot be delivered more frequently due to the time to peak effect of insulin and risk of dose stacking). Continuous insulin infusions are generally titrated every hour with at minimum a rate of 0.5 units/hour running unless glucose levels fall below 100 mg/dL. Subcutaneous insulin management is not appropriate for patients with poor perfusion or those who have no change in glucose after 2 attempted doses.		For patients with hyperglycemia >180, the duration of surgery and level of critical illness can guide whether intermittent subcutaneous insulin vs continuous insulin infusion is appropriate for intraoperative management. Subcutaneous insulin (e.g. Humalog a.k.a. Lispro) is delivered every 2-3 hours based on a sliding scale (cannot be delivered more frequently due to the time to peak effect of insulin and risk of dose stacking). Continuous insulin infusions are generally titrated every hour with at minimum a rate of 0.5 units/hour running unless glucose levels fall below 100 mg/dL. Subcutaneous insulin management is not appropriate for patients with poor perfusion or those who have no change in glucose after 2 attempted doses.

	=== Postoperative management===		=== Postoperative management===
	Continue sliding scale/insulin pump management as post-op.		Continue sliding scale/insulin pump management post-operatively.

	==Related surgical considerations ==		==Related surgical considerations ==
	Certain factors can predispose patients to being either insulin-sensitive or insulin-resistant. Factors that are associated with insulin-sensitivity include: new diagnosis; age > 70 ~~yrs~~; BMI < ~~25kg~~/m2 ~~estimated GFR~~ <~~45ml~~/min. Factors that are associated with insulin-resistance include: BMI >~~35kg~~/m2 ; home TDD > 80 units; steroids > ~~20mg~~ prednisone/day<ref name=":2" />.		Certain factors can predispose patients to being either insulin-sensitive or insulin-resistant intra-operatively. Factors that are associated with insulin-sensitivity include: new diagnosis; age >70 years old; BMI <25 kg/m2, eGFR <45 mL/min. Factors that are associated with insulin-resistance include: BMI >35 kg/m2; home TDD >80 units; steroids >20 mg prednisone/day<ref name=":2" />.

	==Pathophysiology<!-- Describe the pathophysiology of this comorbidity. Add subsections as needed. --> ==		==Pathophysiology<!-- Describe the pathophysiology of this comorbidity. Add subsections as needed. --> ==
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	Humalog (Lispro) is a rapid-acting agent commonly used in sliding scale regimens. It's onset occurs in <15 minutes. Its peak occurs in 30-90 minutes. Duration is generally between 3-5 hours (which is why dosing is performed no more frequently than every 2-3 hours).		Humalog (Lispro) is a rapid-acting agent commonly used in sliding scale regimens. It's onset occurs in <15 minutes. Its peak occurs in 30-90 minutes. Duration is generally between 3-5 hours (which is why dosing is performed no more frequently than every 2-3 hours).

	Long acting agents include glargine (Basaglar/Lantus) and are typically dosed once a day as part of a home insulin regimen.		Long acting agents include glargine (Basaglar/Lantus) and are typically dosed once a day in the evening as part of a home insulin regimen.

	==Epidemiology<!-- Describe the epidemiology of this comorbidity -->==		==Epidemiology<!-- Describe the epidemiology of this comorbidity -->==

Bsumida1 at 12:13, 3 August 2022

2022-08-03T12:13:16Z

← Older revision		Revision as of 05:13, 3 August 2022
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	==Pathophysiology<!-- Describe the pathophysiology of this comorbidity. Add subsections as needed. --> ==		==Pathophysiology<!-- Describe the pathophysiology of this comorbidity. Add subsections as needed. --> ==
	Correctional dosing of insulin is based off of a patients total daily dose (TDD). This may already be known based off of a patients home regimen. For patients whose TDD is unknown, an adult's TDD can be approximated as 0.4U/kg/day<ref name=":2" />.		Correctional dosing of insulin is based off of a patients total daily dose (TDD). This may already be known based off of a patients home regimen. For patients whose TDD is unknown, an adult's TDD can be approximated as 0.4U/kg/day<ref name=":2" />.

			From a patient's TDD, an insulin sensitivity factor (ISF) can be calculated that provides a patient's corrective dosing (i.e. the expected drop in glucose if a patient is given 1U of rapid-acting insulin).

			ISF = 1800/TDD

			As an example, a patient with a TDD of 48U will have an ISF of 37.5 (which can be rounded to 40). Therefore, one possible corrective dosing regimen could be 1U for every 40 >180 (assuming target glucose of 180).

	==Signs and symptoms<!-- Describe the signs and symptoms of this comorbidity. --> ==		==Signs and symptoms<!-- Describe the signs and symptoms of this comorbidity. --> ==
			Intra-operatively, hypoglycemia can lead to cardiac arrhythmia and hemodynamic instability. Hyperglycemia has been shown to increase adverse post-surgical outcomes including surgical site infections, delayed wound healing, and increased length of stay<ref>{{Cite web\|url=https://pubs.asahq.org/anesthesiology/article/126/3/547/19751/Perioperative-Hyperglycemia-ManagementAn-Update\|access-date=2022-08-03\|website=pubs.asahq.org}}</ref>.

	==Diagnosis<!-- Describe how this comorbidity is diagnosed. -->==		==Diagnosis<!-- Describe how this comorbidity is diagnosed. -->==
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	Humalog (Lispro) is a rapid-acting agent commonly used in sliding scale regimens. It's onset occurs in <15 minutes. Its peak occurs in 30-90 minutes. Duration is generally between 3-5 hours (which is why dosing is performed no more frequently than every 2-3 hours).		Humalog (Lispro) is a rapid-acting agent commonly used in sliding scale regimens. It's onset occurs in <15 minutes. Its peak occurs in 30-90 minutes. Duration is generally between 3-5 hours (which is why dosing is performed no more frequently than every 2-3 hours).

	~~===Surgery<!-- Describe surgical procedures used to treat this comorbidity~~. ~~-->===~~		Long acting agents include glargine (Basaglar/Lantus) and are typically dosed once a day as part of a home insulin regimen.

	~~===Prognosis<!-- Describe the prognosis of this comorbidity -->===~~

	==Epidemiology<!-- Describe the epidemiology of this comorbidity -->==		==Epidemiology<!-- Describe the epidemiology of this comorbidity -->==

Bsumida1 at 12:01, 3 August 2022

2022-08-03T12:01:01Z

← Older revision		Revision as of 05:01, 3 August 2022
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	===Intraoperative management<!-- Describe how this comorbidity may influence intraoperative management. -->===		===Intraoperative management<!-- Describe how this comorbidity may influence intraoperative management. -->===
			Institutional practices may vary, however the general principle is to perform close monitoring and maintain euglycemia. Stanford intraoperative glycemic care guidelines recommend targeting a blood glucose of 140-180 during surgery<ref name=":2">{{Cite web\|title=Intraoperative Glycemic Care Guidelines\|url=https://ether.stanford.edu/policies/Intraoperative%20Glycemic%20Care%20Guidelines%20and%20appendix.pdf\|url-status=live}}</ref>. An interval of q2h is appropriate if the patient's blood glucose remains within this range. Sugars between 70-140 warrant closer q1h monitoring, and any sugar below 70 in most adult patients necessitates treatment with a dextrose bolus (e.g. 12.5 g of D50) with subsequent q15 min glucose checks.

	~~=== Postoperative~~ management<!-~~- Describe how this comorbidity may influence postoperative~~ management. ~~-->===~~		For patients with hyperglycemia >180, the duration of surgery and level of critical illness can guide whether intermittent subcutaneous insulin vs continuous insulin infusion is appropriate for intraoperative management. Subcutaneous insulin (e.g. Humalog/Lispro) is delivered every 2-3 hours based on a sliding scale (cannot be delivered more frequently due to the time to peak effect of insulin and risk of dose stacking). Continuous insulin infusions are generally titrated every hour with at minimum a rate of 0.5 units/hour running unless glucose levels fall below 100 mg/dL. Subcutaneous insulin management is not appropriate for patients with poor perfusion or those who have no change in glucose after 2 attempted doses.

	==Related surgical ~~procedures<!~~-- ~~List and briefly describe any procedures which may be performed specifically to treat this comorbidity or its sequelae~~. ~~If none, this section may be removed~~. --> ==		=== Postoperative management===
			Continue sliding scale/insulin pump management as post-op.

			==Related surgical considerations ==
			Certain factors can predispose patients to being either insulin-sensitive or insulin-resistant. Factors that are associated with insulin-sensitivity include: new diagnosis; age > 70 yrs; BMI < 25kg/m2 estimated GFR <45ml/min. Factors that are associated with insulin-resistance include: BMI >35kg/m2 ; home TDD > 80 units; steroids > 20mg prednisone/day<ref name=":2" />.

	==Pathophysiology<!-- Describe the pathophysiology of this comorbidity. Add subsections as needed. --> ==		==Pathophysiology<!-- Describe the pathophysiology of this comorbidity. Add subsections as needed. --> ==
			Correctional dosing of insulin is based off of a patients total daily dose (TDD). This may already be known based off of a patients home regimen. For patients whose TDD is unknown, an adult's TDD can be approximated as 0.4U/kg/day<ref name=":2" />.

	==Signs and symptoms<!-- Describe the signs and symptoms of this comorbidity. --> ==		==Signs and symptoms<!-- Describe the signs and symptoms of this comorbidity. --> ==
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	==Treatment<!-- Summarize the treatment of this comorbidity. Add subsections as needed. -->==		==Treatment<!-- Summarize the treatment of this comorbidity. Add subsections as needed. -->==

	===Medication<!-~~- Describe medications used to manage this comorbidity~~. --~~>===~~		===Medication===
			Humalog (Lispro) is a rapid-acting agent commonly used in sliding scale regimens. It's onset occurs in <15 minutes. Its peak occurs in 30-90 minutes. Duration is generally between 3-5 hours (which is why dosing is performed no more frequently than every 2-3 hours).

	===Surgery<!-- Describe surgical procedures used to treat this comorbidity. -->===		===Surgery<!-- Describe surgical procedures used to treat this comorbidity. -->===

Nkamdar: pre-operative medication adjustments

2021-07-13T14:55:33Z

pre-operative medication adjustments

@@ Line 85: / Line 85: @@
 |Do not take
 |Can cause euglycemic DKA<ref name=":1" /> if not stopped in advance of surgery
 |}

Nkamdar: pre-operative drug adjustments

2021-07-13T14:46:02Z

pre-operative drug adjustments

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 ===Preoperative optimization<!-- Describe how this comorbidity may influence preoperative evaluation and optimization of patients. -->===
-* No overt indications for case cancellations for poorly controlled diabetes except if patients are in diabetes ketoacidosis (DKA) or hyperosmolar osmotic non-ketotic crisis (HONK)
+* No overt indications for case cancellations for poorly controlled diabetes<ref>{{Cite journal|last=Vann|first=Mary Ann|date=2014-06|title=Management of Diabetes Medications for Patients Undergoing Ambulatory Surgery|url=https://linkinghub.elsevier.com/retrieve/pii/S1932227514000226|journal=Anesthesiology Clinics|language=en|volume=32|issue=2|pages=329–339|doi=10.1016/j.anclin.2014.02.008}}</ref><ref>{{Cite journal|last=Joshi|first=Girish P.|last2=Chung|first2=Frances|last3=Vann|first3=Mary Ann|last4=Ahmad|first4=Shireen|last5=Gan|first5=Tong J.|last6=Goulson|first6=Daniel T.|last7=Merrill|first7=Douglas G.|last8=Twersky|first8=Rebecca|date=2010-12|title=Society for Ambulatory Anesthesia Consensus Statement on Perioperative Blood Glucose Management in Diabetic Patients Undergoing Ambulatory Surgery:|url=http://journals.lww.com/00000539-201012000-00009|journal=Anesthesia & Analgesia|language=en|volume=111|issue=6|pages=1378–1387|doi=10.1213/ANE.0b013e3181f9c288|issn=0003-2999}}</ref> except if patients are in diabetes ketoacidosis (DKA) or hyperosmolar osmotic non-ketotic crisis (HONK)
 * Postoperative blood glucose greater than 140 mg/dL is found in as many as 40% of patient undergoing non-cardiac surgery and almost 25% of those patients demonstrate a blood glucose greater than 180 mg/dL during the operative and immediate post-operative period<ref>{{Cite journal|last=Frisch|first=A.|last2=Chandra|first2=P.|last3=Smiley|first3=D.|last4=Peng|first4=L.|last5=Rizzo|first5=M.|last6=Gatcliffe|first6=C.|last7=Hudson|first7=M.|last8=Mendoza|first8=J.|last9=Johnson|first9=R.|last10=Lin|first10=E.|last11=Umpierrez|first11=G. E.|date=2010-08-01|title=Prevalence and Clinical Outcome of Hyperglycemia in the Perioperative Period in Noncardiac Surgery|url=http://care.diabetesjournals.org/cgi/doi/10.2337/dc10-0304|journal=Diabetes Care|language=en|volume=33|issue=8|pages=1783–1788|doi=10.2337/dc10-0304|issn=0149-5992|pmc=PMC2909062|pmid=20435798}}</ref><ref>{{Cite journal|last=Levetan|first=C. S.|last2=Passaro|first2=M.|last3=Jablonski|first3=K.|last4=Kass|first4=M.|last5=Ratner|first5=R. E.|date=1998-02-01|title=Unrecognized Diabetes Among Hospitalized Patients|url=http://care.diabetesjournals.org/cgi/doi/10.2337/diacare.21.2.246|journal=Diabetes Care|language=en|volume=21|issue=2|pages=246–249|doi=10.2337/diacare.21.2.246|issn=0149-5992}}</ref>
 * Data shows mixed reduction of mortality with good blood glucose control in surgical patients<ref>{{Cite journal|last=Buchleitner|first=Ana Maria|last2=Martínez-Alonso|first2=Montserrat|last3=Hernández|first3=Marta|last4=Solà|first4=Ivan|last5=Mauricio|first5=Didac|date=2012-09-12|editor-last=Cochrane Metabolic and Endocrine Disorders Group|title=Perioperative glycaemic control for diabetic patients undergoing surgery|url=https://onlinelibrary.wiley.com/doi/10.1002/14651858.CD007315.pub2|journal=Cochrane Database of Systematic Reviews|language=en|doi=10.1002/14651858.CD007315.pub2}}</ref>, but a reduction in surgical site infection risk<ref>{{Cite journal|last=Kroin|first=Jeffrey S.|last2=Buvanendran|first2=Asokumar|last3=Li|first3=Jinyuan|last4=Moric|first4=Mario|last5=Im|first5=Hee-Jeong|last6=Tuman|first6=Kenneth J.|last7=Shafikhani|first7=Sasha H.|date=2015-06|title=Short-Term Glycemic Control Is Effective in Reducing Surgical Site Infection in Diabetic Rats:|url=http://journals.lww.com/00000539-201506000-00018|journal=Anesthesia & Analgesia|language=en|volume=120|issue=6|pages=1289–1296|doi=10.1213/ANE.0000000000000650|issn=0003-2999}}</ref>
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 ===== <u>Pre-operative medication adjustments</u>: =====
 ===Intraoperative management<!-- Describe how this comorbidity may influence intraoperative management. -->===

Nkamdar: Changes in pre-op optimization

2021-07-13T14:27:43Z

Changes in pre-op optimization

← Older revision		Revision as of 07:27, 13 July 2021
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	* No overt indications for case cancellations for poorly controlled diabetes except if patients are in diabetes ketoacidosis (DKA) or hyperosmolar osmotic non-ketotic crisis (HONK)		* No overt indications for case cancellations for poorly controlled diabetes except if patients are in diabetes ketoacidosis (DKA) or hyperosmolar osmotic non-ketotic crisis (HONK)
	* Consider case delay alongside surgery team if BG > ~~200~~ mg/dL and case is elective and a prothesis or synthetic biofilm will be inserted into the patient during surgery (i.e. prothesis, intraocular lens, joint replacement, graft, etc).		* Postoperative blood glucose greater than 140 mg/dL is found in as many as 40% of patient undergoing non-cardiac surgery and almost 25% of those patients demonstrate a blood glucose greater than 180 mg/dL during the operative and immediate post-operative period<ref>{{Cite journal\|last=Frisch\|first=A.\|last2=Chandra\|first2=P.\|last3=Smiley\|first3=D.\|last4=Peng\|first4=L.\|last5=Rizzo\|first5=M.\|last6=Gatcliffe\|first6=C.\|last7=Hudson\|first7=M.\|last8=Mendoza\|first8=J.\|last9=Johnson\|first9=R.\|last10=Lin\|first10=E.\|last11=Umpierrez\|first11=G. E.\|date=2010-08-01\|title=Prevalence and Clinical Outcome of Hyperglycemia in the Perioperative Period in Noncardiac Surgery\|url=http://care.diabetesjournals.org/cgi/doi/10.2337/dc10-0304\|journal=Diabetes Care\|language=en\|volume=33\|issue=8\|pages=1783–1788\|doi=10.2337/dc10-0304\|issn=0149-5992\|pmc=PMC2909062\|pmid=20435798}}</ref><ref>{{Cite journal\|last=Levetan\|first=C. S.\|last2=Passaro\|first2=M.\|last3=Jablonski\|first3=K.\|last4=Kass\|first4=M.\|last5=Ratner\|first5=R. E.\|date=1998-02-01\|title=Unrecognized Diabetes Among Hospitalized Patients\|url=http://care.diabetesjournals.org/cgi/doi/10.2337/diacare.21.2.246\|journal=Diabetes Care\|language=en\|volume=21\|issue=2\|pages=246–249\|doi=10.2337/diacare.21.2.246\|issn=0149-5992}}</ref>
			* Data shows mixed reduction of mortality with good blood glucose control in surgical patients<ref>{{Cite journal\|last=Buchleitner\|first=Ana Maria\|last2=Martínez-Alonso\|first2=Montserrat\|last3=Hernández\|first3=Marta\|last4=Solà\|first4=Ivan\|last5=Mauricio\|first5=Didac\|date=2012-09-12\|editor-last=Cochrane Metabolic and Endocrine Disorders Group\|title=Perioperative glycaemic control for diabetic patients undergoing surgery\|url=https://onlinelibrary.wiley.com/doi/10.1002/14651858.CD007315.pub2\|journal=Cochrane Database of Systematic Reviews\|language=en\|doi=10.1002/14651858.CD007315.pub2}}</ref>, but a reduction in surgical site infection risk<ref>{{Cite journal\|last=Kroin\|first=Jeffrey S.\|last2=Buvanendran\|first2=Asokumar\|last3=Li\|first3=Jinyuan\|last4=Moric\|first4=Mario\|last5=Im\|first5=Hee-Jeong\|last6=Tuman\|first6=Kenneth J.\|last7=Shafikhani\|first7=Sasha H.\|date=2015-06\|title=Short-Term Glycemic Control Is Effective in Reducing Surgical Site Infection in Diabetic Rats:\|url=http://journals.lww.com/00000539-201506000-00018\|journal=Anesthesia & Analgesia\|language=en\|volume=120\|issue=6\|pages=1289–1296\|doi=10.1213/ANE.0000000000000650\|issn=0003-2999}}</ref>
			* Consider case delay alongside surgery team if BG > 250 mg/dL and case is elective and a prothesis or synthetic biofilm will be inserted into the patient during surgery (i.e. prothesis, intraocular lens, joint replacement, graft, etc).
	* Obtain pre-operative HgA1c if one has not been obtained via primary care in last 3 months prior to surgery		* Obtain pre-operative HgA1c if one has not been obtained via primary care in last 3 months prior to surgery
	** If HgA1c > 8.0 - evidence shows greater incidence of post-operative hyperglycemia during patient recovery		** If HgA1c > 8.0 - evidence shows greater incidence of post-operative hyperglycemia during patient recovery

Nkamdar at 23:53, 12 July 2021

2021-07-12T23:53:49Z

← Older revision		Revision as of 16:53, 12 July 2021
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	The diagnosis of diabetes is made based on fasting blood glucose levels and hemoglobin A1c levels. The diabetic population in the United States is both increasing in incidence and prevalence within the last decade. This disease affects multiple organ systems that have anesthetic implications including cardiovascular health, renal disease, peripheral neurologic function, and gastrointestinal emptying requiring preoperative optimization and intraoperative control.		The diagnosis of diabetes is made based on fasting blood glucose levels and hemoglobin A1c levels. The diabetic population in the United States is both increasing in incidence and prevalence within the last decade. This disease affects multiple organ systems that have anesthetic implications including cardiovascular health, renal disease, peripheral neurologic function, and gastrointestinal emptying requiring preoperative optimization and intraoperative control.

	Cystic fibrosis patients have an acquired form of diabetes as the most common co-morbidity of cystic fibrosis		Cystic fibrosis patients have an acquired form of diabetes as the most common co-morbidity of cystic fibrosis (20% of adolescents and 40-50% of adults).<ref>{{Cite journal\|last=Association\|first=American Diabetes\|date=2021-01-01\|title=2. Classification and Diagnosis of Diabetes: Standards of Medical Care in Diabetes—2021\|url=https://care.diabetesjournals.org/content/44/Supplement_1/S15\|journal=Diabetes Care\|language=en\|volume=44\|issue=Supplement 1\|pages=S15–S33\|doi=10.2337/dc21-S002\|issn=0149-5992\|pmid=33298413}}</ref>

	==Anesthetic implications<!-- Briefly summarize the anesthetic implications of this comorbidity. -->==		==Anesthetic implications<!-- Briefly summarize the anesthetic implications of this comorbidity. -->==

Nkamdar: Body of article.

2021-07-12T18:50:16Z

Body of article.

← Older revision		Revision as of 11:50, 12 July 2021
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	The diagnosis of diabetes is made based on fasting blood glucose levels and hemoglobin A1c levels. The diabetic population in the United States is both increasing in incidence and prevalence within the last decade. This disease affects multiple organ systems that have anesthetic implications including cardiovascular health, renal disease, peripheral neurologic function, and gastrointestinal emptying requiring preoperative optimization and intraoperative control.		The diagnosis of diabetes is made based on fasting blood glucose levels and hemoglobin A1c levels. The diabetic population in the United States is both increasing in incidence and prevalence within the last decade. This disease affects multiple organ systems that have anesthetic implications including cardiovascular health, renal disease, peripheral neurologic function, and gastrointestinal emptying requiring preoperative optimization and intraoperative control.

			Cystic fibrosis patients have an acquired form of diabetes as the most common co-morbidity of cystic fibrosis

	==Anesthetic implications<!-- Briefly summarize the anesthetic implications of this comorbidity. -->==		==Anesthetic implications<!-- Briefly summarize the anesthetic implications of this comorbidity. -->==
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	===Preoperative optimization<!-- Describe how this comorbidity may influence preoperative evaluation and optimization of patients. -->===		===Preoperative optimization<!-- Describe how this comorbidity may influence preoperative evaluation and optimization of patients. -->===

	* No overt indications for case cancellations for poorly controlled diabetes		* No overt indications for case cancellations for poorly controlled diabetes except if patients are in diabetes ketoacidosis (DKA) or hyperosmolar osmotic non-ketotic crisis (HONK)
	* Consider case delay alongside surgery team if BG > 200 mg/dL and case is elective and a prothesis or synthetic biofilm will be inserted into the patient during surgery (i.e. prothesis, intraocular lens, joint replacement, graft, etc).		* Consider case delay alongside surgery team if BG > 200 mg/dL and case is elective and a prothesis or synthetic biofilm will be inserted into the patient during surgery (i.e. prothesis, intraocular lens, joint replacement, graft, etc).
	* Obtain pre-operative HgA1c if one has not been obtained via primary care in last 3 months prior to surgery		* Obtain pre-operative HgA1c if one has not been obtained via primary care in last 3 months prior to surgery
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	==Diagnosis<!-- Describe how this comorbidity is diagnosed. -->==		==Diagnosis<!-- Describe how this comorbidity is diagnosed. -->==
			Diagnosis of diabetes can be made by a variety of ways:

			# Fasting plasma glucose ≥ 126mg/dL
			# Two-hour plasma glucose ≥ 200mg/dL
			# A1C ≥ 6.5 prior to initiating anti-hyperglycemic medications

	==Treatment<!-- Summarize the treatment of this comorbidity. Add subsections as needed. -->==		==Treatment<!-- Summarize the treatment of this comorbidity. Add subsections as needed. -->==

Nkamdar: added pre-operative optimization

2021-07-12T18:34:48Z

added pre-operative optimization

← Older revision		Revision as of 11:34, 12 July 2021
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	* No overt indications for case cancellations for poorly controlled diabetes		* No overt indications for case cancellations for poorly controlled diabetes
	* Consider case delay if ~~cases are~~ elective and a prothesis or synthetic biofilm will be inserted into the patient during surgery		* Consider case delay alongside surgery team if BG > 200 mg/dL and case is elective and a prothesis or synthetic biofilm will be inserted into the patient during surgery (i.e. prothesis, intraocular lens, joint replacement, graft, etc).
			* Obtain pre-operative HgA1c if one has not been obtained via primary care in last 3 months prior to surgery
			** If HgA1c > 8.0 - evidence shows greater incidence of post-operative hyperglycemia during patient recovery

			===== <u>Pre-operative medication adjustments</u>: =====

	===Intraoperative management<!-- Describe how this comorbidity may influence intraoperative management. -->===		===Intraoperative management<!-- Describe how this comorbidity may influence intraoperative management. -->===

Nkamdar at 15:59, 12 July 2021

2021-07-12T15:59:57Z

← Older revision		Revision as of 08:59, 12 July 2021
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	===Preoperative optimization<!-- Describe how this comorbidity may influence preoperative evaluation and optimization of patients. -->===		===Preoperative optimization<!-- Describe how this comorbidity may influence preoperative evaluation and optimization of patients. -->===

			* No overt indications for case cancellations for poorly controlled diabetes
			* Consider case delay if cases are elective and a prothesis or synthetic biofilm will be inserted into the patient during surgery

	===Intraoperative management<!-- Describe how this comorbidity may influence intraoperative management. -->===		===Intraoperative management<!-- Describe how this comorbidity may influence intraoperative management. -->===