Anesthesia in the News
  • Anesthesia Considerations for the Diabetic Patient

    Diabetes mellitus is the most common metabolic condition worldwide resulting in approximately 20% of surgical patients presenting with this condition.  It is a major risk-factor for worse outcomes after surgery including mortality; infective and non-infective complications; and increased length of hospital stay.

    However, because diabetes is a modifiable risk-factor, programs to improve medical management have the potential to reduce perioperative complications and the risk of harm.  Regional anesthesia has well-documented benefits in promoting the restoration of function, but one recent review cautions that there are legitimate concerns that the incidence of complications of regional anesthesia in patients with diabetes is higher.

    The objective of the recent review published in the journal Anaesthesia was to explore in detail the various potential advantages and disadvantages of regional anesthesia in patients with diabetes in order to allow anesthesia practitioners to undertake more informed shared decision-making and potentially modify their anesthetic technique for patients with diabetes.

    7 advantages, 6 cautions

    The review authors first cite the literature that itemizes the numerous potential advantages that regional anesthesia present over general anesthesia — all of which, they note, are potentially more pronounced for patient with diabetes.  These advantages include maintenance of self-ventilation without the loss of airway patency; reduction of the risk of ventilatory failure; better immediate postoperative pain management; earlier resumption of normal diet; minimization of the risk of postoperative nausea and vomiting; reduction in the transition to chronic postoperative pain states in some settings; attenuation of the stress response to surgery; better patient satisfaction; and reduced rates of venous thromboembolism.

    However, the result of their literature exploration also reveals that, beyond providing excellent postoperative analgesia if used and administered correctly, evidence for a clinically important effect of regional anesthesia on longer-term patient outcomes is inconsistent and limited to certain outcomes.

    Their review search further finds that the 6 chief benefits of avoiding general anesthesia in the diabetic patient group are avoidance of potentially difficult tracheal intubation; avoidance of aspiration; promotion of earlier resumption of drinking, eating, and mobilization; attenuation of the stress response to surgery; opioid-sparing benefits; and shorter length of hospital stay.

    Risk mitigation

    While their review illustrates the increased risks and benefits of regional anesthesia in patients with diabetes, the authors emphasize that, for those benefits to be realized, the additional risks need to be mitigated.  These include the risks of physical trauma to nerves; risks of prolonged nerve block; neurotoxicity risk; infection risk; and potential medicolegal risks associated with shared decision-making and its documentation.

    Establish policies

    As there are no studies comparing surgical and patient-reported outcomes in patients with diabetes undergoing regional versus general anesthesia, the review authors advise that clinicians use their judgement and engage with their patients in reaching the decision on the most appropriate anesthetic technique.

    In summary, anesthesia providers should know that the metabolic and subsequent structural changes associated with diabetes increase the incidence of complications with regional anesthesia in this patient cohort.

    Finally, when regional anesthesia is contemplated, the authors call for hospitals to establish policies to manage these risks, and ensure that comprehensive, shared decision-making occurs and is thoroughly documented.  In these ways, they contend that the full benefits of regional anesthesia can be realized for this vulnerable group of patients.

    More details of this important review, “Regional anaesthesia in patients with diabetes.” Anaesthesia. 2021 Jan;76 Suppl 1:127-135., can be found here: https://pubmed.ncbi.nlm.nih.gov/33426661/