Sugar Before Surgery
Health authorities are constantly reminding people with diabetes about the importance of blood sugar control. But along the way it seems they've forgotten to reinforce that message with surgeons - and patients are paying the price.
As the legions of people with type II diabetes and pre-diabetic conditions has ballooned over the last few decades, researchers have learned more and more about how insulin and glucose affect the body. We know that uncontrolled levels of glucose in the blood over time increase the risk of heart disease, kidney failure, vision loss, and circulatory problems, just to name a few.
But what most people with diabetes don't know is that uncontrolled blood glucose levels put you at higher risk for complications during surgery. And these are serious complications we're talking about: life-threatening blood clots, infection, kidney failure, respiratory failure, and even death. In general, surgery patients with diabetes spend more time in the hospital recovering from surgery, and have poorer outcomes.
Research has revealed many explanations for this disturbing trend. Anesthesia and other chemical agents used during surgery may affect glucose levels, or interfere with the action of diabetes drugs. Even body temperature, which is intentionally lowered during some types of surgery, can affect glucose levels. And we know that stress can cause glucose to spike - and I would guess going in for surgery is fairly stressful for most people.
But this risk isn't just for people with diabetes - these factors can trigger a glucose spike even in people that haven't been diagnosed.
You'd think surgeons would be clued in to this - but in many cases, they're not. It's one of the drawbacks on the hyper-specialized world that medical has become. Surgeons do surgery - and not even all surgery, just their surgical specialty - and that's all. Cardiologists do cardiology, endocrinologists do endocrinology, and so on. This tunnel vision approach may make them outstanding in their particular field - but it doesn't always mean that they're providing the best total patient care.
The glucose-surgery link first came to light about a decade ago when authorities started noting that people with diabetes had poorer outcomes after coronary artery bypass surgery. (Considering that 30 percent of all bypass surgeries are performed on people with diabetes, this was something worth noting.) Slowly, hospitals began changing their protocols for cardiac surgery, using IV insulin to tightly control glucose before, during and after surgery. But even today, some ten years later, the new protocols are not universal.
The word has traveled even more slowly in other surgical specialties. Just recently, a report at the annual meeting of the American Society of Anesthesiologists claimed to be the first to link glucose levels to the incidence of pulmonary embolism (serious blood clots) during hip and knee replacement surgery. This life-threatening complication is particularly common in major orthopedic surgeries like this; each year, about 600,000 orthopedic surgery patients develop pulmonary embolism and 200,000 of them die. In this study, patients with high glucose levels were 10 times more likely to develop a pulmonary embolism during surgery than patients with normal glucose levels (though fortunately, none of them died.)
The American Association of Clinical Endocrinologist has issued new guidelines for glucose control in hospitalized patients. But sadly, no surgical or anesthesia associations have followed suit. So there's no guarantee that your specialist, surgeon or hospital is aware is acting on these findings.
But there's no reason you can't act. 99% of the time, these types of surgeries aren't done on an emergency basis - there's time to talk through the issues. If you work with an endocrinologist to manage your diabetes, talk with him before scheduling any type of surgery, particularly cardiac or orthopedic surgery. Have him discuss the new AACE guidelines with your surgeon and check into the protocols used at the hospital where the surgery will be performed. If you don't have an endocrinologist, talk to your specialist and surgeon about the findings linking glucose and outcomes. Any physician who isn't willing to discuss this issue with you is either ignorant, arrogant or both - I recommend you find another one.
