Endocrinology
Anaesthetic management of
the patient with diabetes
Peter Klepsch
Abstract
Diabetes mellitus is the most common endocrine disorder. Type 1 dia-
betes is caused by an immune-mediated destruction of insulin-secreting
islet cells. Type 2 is due to insulin resistance. The prevalence is expected
to double by 2030 in the UK. Patients with both types of diabetes
demand control of their metabolic status, normoglycaemia, the avoid-
ance of ketoacidosis and electrolyte disturbances. The consequences of
long-term diabetes – cardiovascular diseases, autonomic and peripheral
neuropathy, stiff joint syndrome and renal insufficiency as well as the
associations of type 2 diabetes of obesity and lack of exercise – demand
understanding and skill from the anaesthetist. A good preoperative eval-
uation of long-term effects such as coronary heart disease, hypertension
and renal insufficiency plus the risk of difficult intubation and pulmonary
aspiration are of major importance. The aim is perioperative homeos-
tasis of electrolytes and blood glucose as well as the maintenance of
normovolaemia and maximal reduction of perioperative stress. Sufficient
postoperative pain relief and prevention of nausea and vomiting ensure
early enteral feeding. The avoidance of infection with calculated antibi-
otic therapy, early mobilization and physiotherapy are essential. Minor
surgery can often be performed as a day case. This demands adequate
care at home and motivation and compliance of the patient. Day case
centres should implement guidelines for the treatment of patients with
diabetes, and strictly comply with them. There is no evidence that an-
aesthetic technique influences morbidity or mortality in patients with
diabetes.
Keywords anaesthesia; day surgery; diabetes mellitus; glucose–insulin–
potassium regime; obesity; oral hypoglycaemics
There are an estimated 2.35 million people with diabetes in Eng-
land. This is predicted to reach more than 2.5 million by 2010,
of which 9% of cases will be due to an increase in obesity. The
prevalence in the UK is expected to double by 2030. Currently,
10% of hospital in-patient spending is used for the care of people
with diabetes.1 Weight gain and abdominal or visceral fat, inde-
pendent of body mass index, are associated with an increased
risk of diabetes. Diabetes shortens life expectancy by 10 years
in type 2 and 20 years in type 1. The causes of death in 80%
of these patients are cardiovascular events. Long-term intensive
Peter Klepsch is Locum Consultant Anaesthetist at Frenchay Hospital,
Bristol, UK. He qualified from Free University Medical School Berlin,
Germany. He trained in anaesthetics in Berlin. His special interest is
day case anaesthesia, total intravenous anaesthesia and regional
anaesthesia.
ANAESTHESIA AND INTENSIVE CARE MEDICINE 9:10
control of blood glucose has been shown to decrease microvas-
cular complications, but not to reduce macrovascular complica-
tions, diabetes-related mortality or overall mortality.
Types of diabetes
Type 1 diabetes (T1DM; previously known as insulin-depen-
dent or childhood-onset diabetes) results from a failure of insu-
lin secretion (Table 1). This is caused by an immune-mediated
destruction of more than 90% of insulin-secreting islet cells.
Diabetes-associated autoantibodies may be present at the time
of diagnosis, but may be undetectable years after onset. Type 1
diabetes affects genetically predisposed individuals with altered
human lymphocyte antigen (HLA) on the short arm of chromo-
some 6 (HLA-DR3, HLA-DR4 and HLA-DR3/DR4 phenotypes).
The complete absence of insulin in type 1 diabetes leads to
lipolysis, proteolysis and ketogenesis. The treatment is insulin
substitution.
Type 2 diabetes (T2DM; previously known as non-insulin-
­dependent or adult-onset diabetes) is caused by insulin resistance
usually associated with defective insulin secretion (Table 1). It
can often be treated by a combination of diet and oral hypogly-
caemic drugs, although some might require exogenous insulin.
Of those patients with type 2 diabetes, 80% are obese.
Impaired glucose tolerance (IGT) and impaired fasting glucose
(IFG) are intermediate conditions in the transition between nor-
mality and diabetes (Table 1). Patients with IGT or IFG are at
high risk of progressing to type 2 diabetes. In the UK, 17% of
individuals aged 40–65 are affected.
Gestational diabetes constitutes any glucose abnormality that
develops during pregnancy and disappears after delivery. It
affects 4% of pregnant women. Long-term follow-up studies
show that the risk of progressing to diabetes after pregnancy is
about 70%.
Other forms of diabetes include diabetes secondary to other
pathological conditions, for example pancreatitis, trauma or
surgery to the pancreas, drug or chemically induced diabetes or
WHO criteria
Fasting blood 2-hour blood glucose
glucose (mmol/litre) following
(mmol/litre) standard glucose challenge
Diabetes ≥ 7.0 ≥ 11.1
Impaired glucose < 7.0 ≥ 7.8 but < 11.1
tolerance
Impaired fasting ≥ 6.1 but < 7.0 < 7.8
glucose
One positive blood test is required in a symptomatic patient, whereas two
positive blood tests are necessary in an asymptomatic patient
Table 1
441 © 2008 Elsevier Ltd. All rights reserved.
 Endocrinology

­ iabetes related to specific single genetic mutations that may lead

d
to rare forms of diabetes. Oral hypoglycaemics

Biguanides
Treatment
Decrease hepatic glucose output and increase insulin action
The treatment of diabetes includes diet, oral hypoglycaemic • Metformin: Metformin, Glucophage, Glucophage SR (usually
drugs and insulin. The primary prevention of T2DM is avoidance first line)
and treatment of obesity.
 Sulphonylureas
Increased release of endogenous insulin and enhanced insulin
Type 1 diabetes
receptor function by binding to ATP-dependent K+ channels in
Insulin substitution is the treatment for T1DM. This is produced
pancreatic β-cells
from beef or pork pancreas, recombinant technology from Esche-
Long-acting
richia coli or human analogue insulin. Treatment regimes include
• Chlorpropamide: Chlorpropamide
a combination of three different groups of insulin:
• Glibenclamide: Glibenclamide, Daonil, Semi-Daonil, Euglucon
• short-acting, rapid-onset soluble insulin
Shorter-acting
• soluble insulin mixed with protamine or zinc salts to produce
• Gliclazide: Gliclazide, Diamicron, Diamicron MR
a longer action but keeping the rapid onset
• Glimepiride: Amaryl
• long-acting insulin; insulin glargine, a long-acting insulin,
• Glipizide: Glipizide, Glibenese, Minodiab
is becoming popular, especially in combination with short-
• Gliquidone: Glurenorm
­acting insulin before meals.
• Tolbutamide: Tolbutamide
The insulin is given either as single subcutaneous injections
or by using a continuous subcutaneous injection via a pump.  Thiazolidinediones
Increased peripheral glucose uptake and decreased
Type 2 diabetes gluconeogenesis
First-line treatment is the alteration of lifestyle and diet. If that • Pioglitazone: Actos
fails, the use of oral hypoglycaemic drugs or insulin treatment • Rosiglitazone: Avandia, Avandament (combination with
becomes necessary. For the different groups of oral hypoglycae- metformin)
mic drugs see Table 2.
 Acarbose
Inhibits intestinal α-glycosidase, delays digestion and absorption
Acute medical presentations of starch and sucrose
• Glucobay
• Hypoglycaemia: tachycardia, sweating, tremor, confusion and
coma; may be associated with fasting, β-blocker administration  Meglitinides
or alcohol intake. Stimulates insulin secretion by binding to ATP-dependent K+
• Diabetic ketoacidosis: uncontrolled catabolism associated channels in pancreatic β-cells
with insulin deficiency. • Nateglinide: Starlix
• Hyperosmolar non-ketotic coma: hyperglycaemia without keto- • Repaglinide: NovoNorm
sis, commonly present in elderly patients with type 2 diabetes.
Table 2

Systemic associations in patients with diabetes

Systemic complications become more common with increasing
duration of the disease. These are mainly effects of macroangi-
opathy and microangiopathy (Table 3). Microvascular complica-
tions predominate in patient with T1DM, whereas macrovascular
complications are more common in patients with T2DM.
Cardiovascular
Diabetes is considered as a coronary artery disease equivalent and
might support perioperative β-blockade and statin therapy. Auto-
nomic neuropathy can lead to silent ischaemia, resting tachycardia,
orthostatic hypotension, cardiac dysrhythmias and sudden death.
In addition to the above cardiovascular symptoms, autonomic
neuropathy can lead to bladder atony, altered regulation of breath-
ing, asymptomatic hypoglycaemia, impotence and gastroparesis.
Renal failure
This reflects a lesion in the microvasculature of the renal glom-
erulus and occurs eventually in one-third of patients with T1DM.
Microalbuminuria is an early sign of diabetic nephropathy. Renal
impairment alters drug clearance and is a positive predictor for
the presence of cardiovascular disease.
Stiff joint syndrome
An estimated 30–40% of patients with T1DM show signs of lim-
ited joint mobility. This can involve the atlanto-occipital joint
and may lead to difficulties in laryngoscopy and tracheal intuba-
tion. The ‘prayer sign’, an inability to approximate the palmar
surface of the interphalangeal joints, correlates with the presence
of the stiff joint syndrome.
Other
Patients with diabetes show an increased risk of wound infection
and delayed wound healing. In acute hyperglycaemia or badly
controlled diabetes, gastric emptying can be significantly delayed
(Figure 1).
The obese or morbidly obese patient has additional risks of
a potential difficult airway, higher ventilation pressures, lower

ANAESTHESIA AND INTENSIVE CARE MEDICINE 9:10 442 © 2008 Elsevier Ltd. All rights reserved.

Long-term complications of diabetes mellitus
• Macroangiopathy: coronary artery disease, cerebrovascular
disease and peripheral vascular disease, hypertension
• Microangiopathy: nephropathy, retinopathy and disorders
of the nervous system such as autonomic neuropathy and
peripheral neuropathy
• Other: stiff joint syndrome, decreased lung diffusion capacity
and lung volumes, increased risk of postoperative wound
infection and delayed wound healing
Table 3
oxygen reserve and a higher risk of developing atelectasis. Alone
or in combination with smoking, this causes a higher incidence
of chest infections.
Management of anaesthesia
Preoperative evaluation of patients should focus on the possible
complications of diabetes. Special attention should be given to
silent ischaemia, cerebrovascular disease, renal failure, orthostatic
dysregulation and the potential for difficult intubation. Preop-
erative urea and electrolyte levels and blood glucose should be
checked, plus a full blood count/clotting screen, if appropriate for
the surgery. HbA1c and urine analysis for albumin and ketones can
also give useful information about glucose control. ECG should be
considered in all patients even if they are below the age when a
Gastric emptying
100
Radionuclide remaining in stomach (%)
90
*
80
* Postoperative management
70 * The postoperative aims are sufficient pain relief to avoid stress
60
50
40
30
0 20 40 60
Time (minutes)
Gastric emptying of the solid test meal (99mTc sulphur colloid-labelled
chicken liver/beef stew). Red circles, in patients with diabetes;
blue circles, in patients with diabetes after metoclopramide (10 mg
intravenous bolus); and green circles, in control subjects.
*Statistically significant differences (P < 0.05) compared with untreated
patients with diabetes. Standard deviations are shown. Reproduced with
permission from Wright RA, Clemente R, Wathen R. Diabetic gastroparesis: an
abnormality of gastric emptying. Am J Med Sci 1985; 289: 240-2.3
Figure 1
ANAESTHESIA AND INTENSIVE CARE MEDICINE 9:10
Endocrinology
routine ECG is done. Chest radiograph and echocardiogram might
be indicated if the routine tests and the clinical history indicate it.
In the UK, all patients with diabetes should have an annual
review. It will mostly be undertaken in a primary care setting and
should include assessment of microvascular and macrovascular
status, HbA1c, blood pressure and cholesterol. To avoid duplica-
tion of effort, it may be possible to obtain this review from the
patient’s GP.
Blood glucose should be measured 1 hour preoperatively,
hourly perioperatively and 2 hourly postoperatively until the
patient is eating and drinking. Aggressive treatment of preopera-
tive hyperglycaemia may help to reduce the incidence of intra-
and postoperative elevation of blood glucose.
Intraoperative management
The following factors influence perioperative blood glucose lev-
els: diabetes itself, starvation (pre- and postoperative), hormonal
and metabolic response to surgery, anaesthetic drugs and immo-
bilization.
The goal for the management of anaesthesia in patients with
diabetes is maintaining normoglycaemia, normal electrolyte
homeostasis and avoiding ketoacidosis and dehydration. Tight
(4.4–6.1 mmol/litre) glucose control has been shown to improve
outcome in patients in intensive care units mainly after cardiac
surgery, but these data have not yet been extrapolated to include
the general surgical population.
The widely accepted aim is a blood glucose level < 10 mmol/
litre. This is achieved by an infusion of glucose–insulin–­potassium
(GIK) solutions. Blood glucose levels of 12–14 mmol/litre are
associated with major complications such as exacerbation of
ischaemic damage to the brain and myocardium, wound healing
disorders, infection, anastomotic insufficiency, dehydration and
electrolyte loss.
Reducing the perioperative catabolic and sympathetic response
characterized by elevations in circulating catecholamines, growth
hormone, glucagon and cortisol levels is of major importance.
This reduces the depression of insulin levels, hepatic glycolysis
and gluconeogenesis.
*
(with its resulting hormonal and metabolic response) and the
avoidance of postoperative nausea and vomiting to re-establish
* the earliest possible oral dietary intake. Insulin, if given, should
* be continued for at least 2 hours after the first oral intake.
*
* Minor surgery
*
Minor surgery is defined as a patient missing only one meal and
80 100 120 being able to eat or drink within 4 hours of surgery.
Patients with T2DM omit their oral hypoglycaemic medication
on the day of surgery except metformin, which should be omit-
ted from the night before. The patients should be first on the list
and take their oral hypoglycaemic drugs as soon they are able to
have the first meal.
A Cochrane review does not support the 48-hour abstinence
of metformin before anaesthesia because a related lactacidosis is
unlikely. In 176 studies representing 35,000 patient-years there
was no episode of lactacidosis.
443 © 2008 Elsevier Ltd. All rights reserved.
 Endocrinology
Patients with T1DM have half of their usual morning dose
of short- or intermediate-acting insulin, should be first on the
list and aim to have early food intake postoperatively. If blood
glucose exceeds 10 mmol/litre a glucose, insulin and potassium
(GIK) regime should be started. Alternatively, a sliding scale
with separate insulin and glucose–potassium infusions can be
used. The normal insulin doses can be given once the patient is
­eating.
Major surgery
Patients should be admitted the day before surgery to allow suf-
ficient time to correct glucose and electrolyte abnormalities. Oral
hypoglycaemics and insulin should be omitted on the day of sur-
gery and a glucose–insulin regime should be started at least 2
hours prior to surgery. Potassium should be checked frequently
and kept at 4–4.5 mmol/litre to avoid arrhythmias.
Postoperative GIK infusion should be maintained until 2 hours
after the first meal. Start oral hypoglycaemics for patients with
T2DM and the usual insulin regime for patients with T1DM with
the first meal.
The choice of the anaesthetic drug has no influence on the
outcome. Postoperative pain control and stress reduction are
paramount. Minimally invasive surgery and epidural anaesthesia
have been suggested to reduce perioperative insulin resistance
and hyperglycaemia in abdominal surgery.
Day cases
Despite an increased risk of complications in major surgery,
diabetes is not an independent factor for increased morbidity or
mortality after ambulatory surgery. Diabetes per se does not pre-
dict adverse outcome following minor ambulatory surgery, and it
is usually the co-morbidities of patients with diabetes that limit
their suitability as day cases. There is no special limitation for
ambulatory surgery in patients with diabetes.
Following the guidelines for the assessment and management
of patients with diabetes undergoing day surgery,2 minor and
intermediate operations can be carried out if the criteria are ful-
filled (Table 4). Minor surgery can be carried out both first on
the morning or first on the afternoon list but intermediate surgery
first on the morning list only. Minor day surgery consists of pro-
cedures that allow oral intake in the first hour after surgery. In
these cases, the patient omits the morning dose of insulin or oral
hypoglycaemic and takes it with the delayed breakfast after being
operated first on the list. Consider reducing long-acting insulin
taken the night before surgery by one-third.
Patients for minor surgery on the afternoon list take their
normal oral hypoglycaemics or half of their usual morning
dose of insulin with a light breakfast 6 hours before surgery.
After surgery, they have their delayed lunch with their usual
lunchtime medication. If the patient takes insulin only twice a
day, give one-quarter of the daily dose of rapid-acting insulin.
If the patient’s blood glucose level on admission is less then 5
mmol/litre and the patient is on insulin or sulphonylurea con-
sider an infusion of 5% glucose 100 ml/hour. If the blood glu-
cose is above 13 mmol/litre check for intercurrent infection or
the patient not being fasted and consider postponing the sur-
gery. Discharge ­ criteria are the same as for patients without
ANAESTHESIA AND INTENSIVE CARE MEDICINE 9:10
Criteria for selection of patients with diabetes in day
surgery2
○ All usual selection criteria for day surgery met
○ Intermediate surgery can be scheduled for a morning list
○ Patient has no history of:
○ Repeated hypoglycaemic attacks
○ Recurrent admission to hospital with complications related
to diabetes
○ Patient and carer are able to measure blood glucose at home
○ Patient and carer understand about hypoglycaemia and its
treatment
○ HbA1c < 8%
Reproduced with permission from the British Association of Day Surgery
Table 4
­diabetes, except that the blood glucose should be between 5
and 13 mmol/litre.
Intermediate surgery, with postoperative fasting between 1
and 4 hours, should be carried out first on the morning list. The
morning dose of both oral hypoglycaemics and insulin should be
omitted. Patients treated by oral hypoglycaemics whose blood
glucose on admission is below 10 mmol/litre can just be observed
but patients with blood glucose levels above 10 mmol/litre and
all patients taking insulin should be treated with a GIK infusion,
reflecting their blood glucose levels on admission, until they are
ready for a meal.
An alternative to a GIK regime would be the in-hospital admin-
istration of half of the patient’s morning dose as an intermediate
duration insulin in combination with perioperative tight glucose
control and the use of short-acting insulin to treat hyperglycaemia.
Regional anaesthesia
Regional anaesthesia can reduce the stress response and avoids
intubation. Regional anaesthesia is associated with decreased
blood loss and decreased thromboembolic complications.
Regional anaesthesia shortens the time of postoperative fast-
ing and local anaesthesia eliminates perioperative fasting at all.
Regional anaesthesia should be considered in every patient with
diabetes, especially if a difficult airway is likely.
Controversies
Wright et al.3 postulated a delayed gastric emptying in diabetic
patients (Figure 1). A recent study4 concluded: ‘In elective surgi-
cal patients who have fasted before surgery, gastric volumes are
minimal, even in diabetics with severe neuropathic symptoms.
Metoclopramide prophylaxis to reduce gastric volumes seems to
be unnecessary unless the patient has a prolonged history of poor
blood glucose control.’
Eight hours fasting and prokinetic therapy is recommended in
patients whose HbA1c levels exceed 9%.
Some authors5 suggest a possible exacerbation of a periph-
eral neuropathy after regional anaesthesia. This remains unclear.
A recent retrospective study6 in patients with diabetes with
444 © 2008 Elsevier Ltd. All rights reserved.
 Endocrinology
existing polyneuropathy could show an incidence of progression
of ­ neurological symptoms in 0.4% out of 567 patients. It was
unclear whether or not the neuraxial block was the cause of it.
These authors concluded that the risk of severe postoperative
neurological injury in patients with pre-existing peripheral senso-
rimotor neuropathy or diabetic polyneuropathy undergoing neur-
axial anaesthesia or analgesia is relatively uncommon. However,
the risk appears to be higher than in the general population. Clini­
cians should be aware of this potentially high-risk subgroup.
Glucose–insulin–potassium regime
There are generally two ways to run a GIK scheme. It can be run
as one infusion including all three components, which can make
it necessary to change the whole infusion if the blood glucose
is out of range. Alternatively, it can be run as a separate insulin
infusion and a glucose–potassium infusion, which creates the
danger of one part being stopped accidentally resulting in hyper-
or hypoglycaemia. The infusion could contain low glucose con-
centrations of 10–20%, leading to a huge amount of free water,
or 50%, which can be given only through a central line.
There is no clear evidence for the optimal intravenous fluid
for patients with diabetes. However, lactate-containing solutions,
such as Hartmann’s solution, seem to be safe. The administration
of solutions containing only glucose run the risk of hyponatrae-
mia due to overload of free water. ◆
References
1 Department of Health About Diabetes. May 2007. http://www.dh.gov.
uk/en/Healthcare/NationalServiceFrameworks/Diabetes/DH_074762
ANAESTHESIA AND INTENSIVE CARE MEDICINE 9:10
2 British Association of Day Surgery. Day surgery and the diabetic
patient: guidelines for the assessment and management of diabetes
in day surgery patients. London: BADS, 2004.
3 Wright RA, Clemente R, Wathen R. Diabetic gastroparesis: an
abnormality of gastric emptying of solids. Am J Med Sci 1985; 289:
240–2.
4 Jellish WS, et al. Effect of metoclopramide on gastric fluid volumes
in diabetic patients who have fasted before elective surgery.
Anesthesiology 2005; 102: 904–9.
5 Robertshaw HJ. Diabetes: anaesthetic management. Anaesthesia
2006; 61: 1187–90.
6 Hebl JA. Neurologic complications after neuraxial anesthesia or
analgesia in patients with preexisting peripheral sensorimotor
neuropathy or diabetic polyneuropathy. Anesth Analg 2006; 103:
1294–9.
Further reading
British Association of Day Surgery. Day surgery and the diabetic patient:
guidelines for the assessment and management of diabetes in day
surgery patients. London: BADS, 2004.
Hebl JA. Neurologic complications after neuraxial anesthesia or analgesia
in patients with preexisting peripheral sensorimotor neuropathy or
diabetic polyneuropathy. Anesth Analg 2006; 103: 1294–9.
Robertshaw HJ. Diabetes: anaesthetic management. Anaesthesia 2006;
61: 1187–90.
Vivek K. The diabetic surgical patient. Curr Opin Anaesthesiol 2006; 19:
339–45.
Zufiqar A. Advances in diabetic management: implications for
anaesthesia. Anesth Analg 2005; 100: 666–9.
445 © 2008 Elsevier Ltd. All rights reserved.