Management of adults with diabetes undergoing surgery and elective procedures: improving standards

Joint British Diabetes Societies for Inpatient Care


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Introduction

  • Diabetes is the most prevalent long term metabolic condition and its incidence continues to increase. People with diabetes are over-represented in the surgical population. It has been well recognised that poor peri-operative diabetes control is associated with poor surgical outcomes. These include infections, acute kidney injury, myocardial infarction, length of hospital stay, and death
  • Recent work has shown that pre-operative recognition of diabetes and good communication between the clinical teams at all stages of the patient pathway help to minimise the potential for errors, and improve glycaemic control. The stages of the patient journey start in primary care and end when the patient goes home
  • To date, the glycaemic targets for the peri-operative period have remained uncertain, but recently a consensus is being reached and national guidance suggests that for people referred for elective surgery, that the pre-operative HbA1c should be less than 69 mmol/mol (8.5%) to minimise this risk of poor outcomes
  • This Guidelines summary covers primary care referral for surgery. For recommendations on pre-operative assessment, hospital admission, surgery, post-operative care, and discharge, please refer to the full guideline

Primary care referral

Aims

  • Ensure that the potential effects of diabetes and associated co-morbidities on the outcome of surgery are considered before referral for elective procedures
  • Ensure that the relevant medical information is communicated fully at the time of referral
  • Ensure that diabetes and co-morbidities are optimally managed before the procedure

Recommendations

  • Provide the current HbA1c, blood pressure and weight measurements with details of relevant complications and medications in the referral letter
  • Optimise glycaemic control, aiming for an HbA1c of less than 69 mmol/mol before referral if possible, and if it is safe to do so
  • Consider referral to the diabetes specialist team for advice if the HbA1c is greater than 69 mmol/mol (8.5%) and it is felt that further optimisation is safely achievable. A high HbA1c is an indication for intensive blood glucose control but it may not be realistic to delay referral until the HbA1c has been repeated. The referral letter should state if the GP feels that the glycaemic control is as good as it could be, and that the patient is judged to be ready for the elective procedure
  • Patients with hypoglycaemic unawareness should be referred to the diabetes specialist team irrespective of HbA1c
  • Optimise other diabetes related co-morbidities
  • Provide written advice to patients undergoing investigative procedures requiring a period of starvation. Appropriate advice can be found in Appendix 1 and Appendix 2 of the guideline—available at www.diabetologists-abcd.org.uk/JBDS/JBDS_IP_Surgical_Guideline_2015_Full.pdf

GP letter with recommendations for referral of patients for surgery

GP letter with recommendations for referral of patients for surgery

References

full guidelines available from...
www.diabetologists-abcd.org.uk/JBDS/JBDS.htm

Joint British Diabetes Societies for Inpatient Care. Management of adults with diabetes undergoing surgery and elective and elective procedures: improving standards. September 2015


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