Caring for Patients With Diabetes in the Ambulatory Setting

Approximately 37.3 million Americans, nearly 11.3% of the population, are living with diabetes, according to the National Diabetes Statistics Report.1 Given the increase in outpatient surgical procedures, perioperative staff members in the ambulatory setting will care for patients with diabetes with increasing frequency.2 Patients with diabetes are at an increased risk of surgical complications (eg, hypoglycemia, ketosis) because the metabolic changes that can occur during surgery may lead to an abnormal glucose balance.3 As such, perioperative teams must be vigilant in managing the blood glucose in these patients and have an individualized postoperative care plan.1 It is important that perioperative teams develop and practice protocols that minimize the risk of complications for these patients.1 “Every facility should develop and implement a blood glucose management protocol,” said Niraja Rajan, MD, FAAP, FASA, SAMBA-F, professor of anesthesiology at Penn State Health, Pennsylvania, and president of the Society for Ambulatory Anesthesia (SAMBA). “There should be a policy for when and how to treat patients with hyperglycemia and hypoglycemia. It is very important to have that in place.” According to Rajan, the greatest difference between inpatient and outpatient management is the target blood glucose range. The American Diabetes Association recommends a target blood glucose range of 100 and 180 mg/dL within four hours of surgery.4 However, in the ambulatory setting, the SAMBA task force has recommended a more liberal target range for blood glucose (180 to 250 mg/dL).1 This is because the types of procedures performed in the ambulatory setting tend to cause fewer physiological derangements, and patients can return to their PO intake and diabetes medication much more quickly.1 Additionally, the goal of ambulatory surgery is to have the patient ready to leave the facility and return to their activities of daily living—as well as independently managing their diabetes—as soon as possible. “In the ambulatory world, the patient is in charge of their disease management and that's an important thing to recognize,” Rajan said. “We want to disrupt that management as little as possible.” Before the patient arrives at the ambulatory facility, it is important for the nurse who conducts the preadmission phone call to determine how long the individual has had diabetes, how well it is controlled, whether they have had any acute episodes that led them to seek urgent care or resulted in an inpatient admission, and if they have any additional comorbidities, explained Rajan. This is also an appropriate time to determine if the patient has an insulin pump, and if so, where it is located, and if they use a continuous glucose monitor (CGM).1 Patients should be instructed to check their blood glucose the morning of surgery.1 If levels are low, they should initiate treatment and notify the ambulatory surgery facility.1 For those who are fasting, treatment at home may include 4 to 8 oz of clear juice or 15 to 20 g of glucose in gel form; if the patient has already arrived at the facility, IV dextrose can be initiated as an alternative treatment.1 The recommended frequency of blood glucose monitoring can vary by patient, but typically, patients undergoing procedures that take less than two hours only need a blood glucose assessment on admission and before discharge.1 This frequency may be increased for those undergoing procedures that are two hours or longer and/or those who require insulin treatment.1 Those who are administered subcutaneous rapid-acting insulin require monitoring every 90 to 120 minutes.1 In addition, if patients develop hypoglycemia, they will require close monitoring every 15 to 30 minutes until the concentration returns to a safe level.1 Of note, some societies advocate for “carbohydrate loading” in the preoperative setting to reduce perioperative insulin resistance; however, clinical evidence of improved postoperative outcomes remain controversial, and results from a meta-analysis showed that hydration with water offers a similar benefit as preoperative carbohydrate loading.1 “In the ambulatory setting, the SAMBA task force recommends preprocedural hydration with water because carbohydrate loading in diabetic patients can lead to hyperglycemia the morning of surgery,” Rajan said. It is not recommended to postpone ambulatory surgery to achieve a specific A1c level because it can be difficult for patients to significantly change their A1c levels.1 “Trying to achieve the recommended A1c of less than 8 can take a year or more to achieve,” Rajan explained. “If they are waiting a year or more to get something like a carpal tunnel or a cataract surgery, that would not make sense.” However, A1c can be used to assess a patient's glycemic control.1 Therefore, if the patient has an elevated A1c level (greater than 9%), the surgical team should be made aware, so that a plan for continued monitoring and treatment can be developed and, if necessary, a plan for medication adjustments or initiations can be enacted.1 Point-of-care glucose meters (pictured) are recommended to confirm the accuracy of continuous glucose monitoring and automated insulin dosing systems, especially before implementing blood glucose management therapy. If patients arrive to the ambulatory setting with hyperglycemia and symptoms of diabetic ketoacidosis (DKA) or hyperosmolar hyperglycemic state (HHS), their procedure should be postponed and they should be transferred to an emergency department or hospital.1 Similarly, patients with severe hyperglycemia (blood glucose > 300 mg/dL, 16.7 mmol/L) may also need to postpone, unless their procedure is minor (eg, gastrointestinal endoscopy, cataract surgery). However, if the patients arrive with uncomplicated hyperglycemia (absence of DKA or HHS), they can proceed to surgery, as there is limited evidence suggesting that it hinders surgical outcomes.1 “If somebody shows up with significant hyperglycemia, or blood glucose greater than 250, you can treat them with insulin to bring it back down to just below 250,” Rajan said. “Do not try to aggressively correct it and get it to some fantastic normal number. You just want it under 250. Further, it is okay to use insulin even if the patient is not on insulin at home.” Continuous glucose monitors provide frequent blood glucose measurements, commonly providing a measurement every five minutes.1 Although CGMs offer several advantages over point-of-care glucose meters, such as fewer finger sticks and an increased number of blood glucose measurements, they are unreliable in patients with skin infections near the sensor site, significant edema, or severe hypoglycemia or hyperglycemia. The use of point-of-care glucose meters is recommended to confirm the accuracy of CGMs and automated insulin dosing systems, especially before implementing blood glucose management therapy.1 During the procedure, bedside blood glucose measuring devices may be used to measure blood glucose intraoperatively.3 There is currently insufficient data regarding the best strategy or regimen for intraoperative blood glucose management for patients with diabetes in the ambulatory setting.1 The SAMBA task force recommends that every facility create and follow a blood glucose management protocol.1 Many patients use insulin pumps to manage their disease. Rajan noted that patients can be allowed to keep their insulin pump running, if it can be protected from being dislodged or damaged. “You need to make sure that the device is outside the surgical field and can be easily visualized,” she said. “You can keep it running, but you want to make sure you're protecting it.” It is important that discharge planning begins at the time of surgical scheduling so that there is a plan in place for the patients’ oral medications, insulin, and noninsulin injectables. At discharge, patients need specific instructions regarding diabetes management, oral medications, insulin resumption, considerations for their diet disruption, and home blood glucose testing, as well as a physician contact for concerns pertaining to postoperative blood glucose management.1 Handing off patients to the postoperative team should include detailed information about the medications given preoperatively and intraoperatively, the patient's blood glucose level, and the plan for the continued management of the diabetes.5 “It is important that the postoperative care unit nurse receives complete information about the patient,” Rajan said. Postoperatively, the blood glucose should continue to be in the target range, and patients should return to their usual diet and normal medication as soon as clinically safe.5 Nurses should instruct patients to resume their oral medications and injectables when they resume their food intake. If the patient experienced severe postoperative nausea and vomiting, caution should be exercised when restarting antidiabetic medications.1 “You must provide customized discharge instructions based on how quickly they are going to return to their PO intake and whether they are having any nausea and vomiting,” Rajan explained. “There are some types of procedures where the patient may have a restricted intake, like with oral surgery, and you do not want to tell them to start taking all their diabetes medication right away. You tell them to check their glucose frequently and to resume their diabetes medication once normal PO intake has resumed. For most other ambulatory procedures, patients begin PO intake right away, so they can resume their medications.” The number of individuals with diabetes continues to increase and many of these individuals will need to undergo surgery. In the ambulatory setting, a more liberal target blood glucose range is acceptable. The goal is to have the patient home and back to independently managing their own disease with as few disruptions as possible.