Journal of Anesthesia

, Volume 24, Issue 5, pp 748–756 | Cite as

Anesthetic considerations in diabetic patients. Part II: intraoperative and postoperative management of patients with diabetes mellitus

Review Article


Some studies have reported that tight glycemic control in diabetic patients undergoing major surgery improves perioperative morbidity and mortality rates. Recently, however, large randomized studies have shown such control increases the mortality rate, since aggressive glycemic control induces more frequent incidences of hypoglycemia. Diabetic patients have cerebral complications during the perioperative period more often than their nondiabetic counterparts. Further, anesthetic agents have some effects on cerebral circulation and cerebrovascular carbon dioxide reactivity. Hence, anesthesiologists should have adequate knowledge about anesthetic agents that maintain the integrity of the cerebral circulation. Patients with diabetes mellitus (DM) have an increased susceptibility to perioperative infections. Recent work confirmed that a combination of intravenous and subcutaneous insulin as a glucose management strategy had beneficial effects identical with intravenous insulin therapy alone on the reduction of infection rates during the postoperative period.


Diabetes mellitus Tight glycemic control Perioperative management 


  1. 1.
    Thourani VH, Weintraub WS, Stein B, Gebhart SS, Craver JM, Jones EL, Guyton RA. Influence of diabetes mellitus on early and late outcome after coronary artery bypass grafting. Ann Thorac Surg. 1999;67:1045–52.CrossRefPubMedGoogle Scholar
  2. 2.
    Burgos LG, Ebert TJ, Asiddao C, Turner LA, Pattison CZ, Wang-Cheng R, Kampine JP. Increased intraoperative cardiovascular morbidity in diabetics with autonomic neuropathy. Anesthesiology. 1989;70:591–7.CrossRefPubMedGoogle Scholar
  3. 3.
    Knuttgen D, Weidemann D, Doehn M. Diabetic autonomic neuropathy: abnormal cardiovascular reaction under general anesthesia. Klin Wochenschr. 1990;68:1168–72.CrossRefPubMedGoogle Scholar
  4. 4.
    Knuttgen D, Buttner-Belz U, Gernot A, Doehn M. Unstable blood pressure during anesthesia in diabetic patients with autonomic neuropathy. Anaesth Intensivther Notfallmed. 1990;25:256–62.CrossRefGoogle Scholar
  5. 5.
    Linstedt U, Jaeqer H, Petry A. The neuropathy of the autonomic nervous system. An additional anesthetic risk in diabetes mellitus. Anaesthesist. 1993;42:521–7.PubMedGoogle Scholar
  6. 6.
    Vohra A, Kumar S, Charlton AJ, Olukoga AO, Boulton AJ, McLeod D. Effect of diabetes mellitus on the cardiovascular responses to induction of anaesthesia and tracheal intubation. Br J Anaesth. 1993;71:258–61.CrossRefPubMedGoogle Scholar
  7. 7.
    Latson TW, Ashmore TH, Reinhart DJ, Klein KW, Giesecke AH. Autonomic reflex dysfunction in patients presenting for elective surgery is associated with hypotension after anesthesia induction. Anesthesiology. 1994;80:326–37.CrossRefPubMedGoogle Scholar
  8. 8.
    Keyl C, Lemberger P, Palitzsch KD, Hochmuth K, Liebold A, Hobbhahn J. Cardiovascular autonomic dysfunction and hemodynamic response to anesthetic induction in patients with coronary artery disease and diabetes mellitus. Anesth Analg. 1999;88:985–91.CrossRefPubMedGoogle Scholar
  9. 9.
    Khan AA, Khan FA. Haemodynamic response to induction, laryngoscopy and tracheal intubation in diabetic and non-diabetic patients. J Pak Med Assoc. 2009;59:27–30.PubMedGoogle Scholar
  10. 10.
    Charlson ME, MacKenzie CR, Gold JP, Ales KL, Topkins M, Shires GT. Preoperative characteristics predicting intraoperative hypotension and hypertension among hypertensives and diabetics undergoing noncardiac surgery. Ann Surg. 1990;212:66–81.CrossRefPubMedGoogle Scholar
  11. 11.
    Tsueda K, Huang KC, Dumont SW, Wieman TJ, Thomas MH, Heine MF. Cardiac sympathetic tone in anesthetized diabetics. Can J Anesth. 1991;38:20–3.CrossRefPubMedGoogle Scholar
  12. 12.
    Van den Berghe G, Wouters P, Weekers F, Verwaest C, Bruyninckz F, Schetz M, Vlasselaers D, Ferdinande P, Lauwers P, Bouillon R. Intensive insulin therapy in critically ill patients. New Engl J Med. 2001;345:1359–67.CrossRefPubMedGoogle Scholar
  13. 13.
    Ouattara A, Lecomte P, Manach YL, Landi M, Jacqeminet S, Platonov I, Bonnet M, Riou B, Coriat P. Poor intraoperative blood glucose control is associated with a worsened hospital outcome after cardiac surgery. Anesthesiology. 2005;103:687–94.CrossRefPubMedGoogle Scholar
  14. 14.
    Lazar HL, Chipkin SR, Fitzerald CA, Bao Y, Cabral H, Apstein CS. Tight glycemic control in diabetic coronary artery bypass graft patients improves perioperative outcomes and decreases recurrent ischemic events. Circulation. 2004;109:1497–502.CrossRefPubMedGoogle Scholar
  15. 15.
    Doenst T, Wijeysundera D, Karkouti K, Zechner C, Maganti M, Rao V, Borger MA. Hyperglycemia during cardiopulmonary bypass is an independent risk factor for mortality in patients undergoing cardiac surgery. J Thorac Cardiovasc Surg. 2005;130:1144–50.CrossRefPubMedGoogle Scholar
  16. 16.
    Brunkhorst FM, Engel C, Bloos F, Meier-Hellmann A, Ragaller M, Weiler N, Moerer O, Gruendling M, Oppert M, Grond S, Olthoff D, Jaschinski U, John S, Rossaint R, Welte T, Schaefer M, Kern P, Kuhnt E, Kiehntopf M, Hartog C, Natanson C, Loeffler M, Reinhart K, German Competence Network Sepsis (SepNet). Intensive insulin therapy and pentastarch resuscitation in severe sepsis. N Engl J Med. 2008;358:125–39.CrossRefPubMedGoogle Scholar
  17. 17.
    Preiser JC, Devos P, Ruiz-Santana S, Mélot C, Annane D, Groeneveld J, Iapichino G, Leverve X, Nitenberg G, Singer P, Wernerman J, Joannidis M, Stecher A, Chioléro R. Prospective randomised multi-centre controlled trial on tight glucose control by intensive insulin therapy in adult intensive care units: the Glucontrol study. Intensive Care Med. 2009;35:1738–48.CrossRefPubMedGoogle Scholar
  18. 18.
    NICE-SUGAR Study Investigators, Finfer S, Chittock DR, Su SY, Blair D, Foster D, Dhingra V, Bellomo R, Cook D, Dodek P, Henderson WR, Hébert PC, Heritier S, Heyland DK, McArthur C, McDonald E, Mitchell I, Myburgh JA, Norton R, Potter J, Robinson BG, Ronco JJ. Intensive versus conventional glucose control in critically ill patients. N Engl J Med. 2009;360:1283–97.CrossRefPubMedGoogle Scholar
  19. 19.
    Vriesendorp TM, Santen SV, DeVries H, Jonge ED, Rosendaal FR, Schultz MJ, Hoekstra JL. Predisposing factors for hypoglycemia in the intensive care unit. Crit Care Med. 2006;34:96–101.CrossRefPubMedGoogle Scholar
  20. 20.
    Egi M, Bellomo R, Stachowski E, French CJ, Hart GK, Heqarty C, Bailey M. Blood glucose concentrations and outcome of critical illness: the impact of diabetes. Crit Care Med. 2008;36:2249–55.CrossRefPubMedGoogle Scholar
  21. 21.
    Wilson M, Weinreb J, Hoo GW. Intensive insulin therapy in critical care: a review of 12 protocols. Diabetes Care. 2007;30:1005–11.CrossRefPubMedGoogle Scholar
  22. 22.
    Raucoules-Aime M, Labib Y, Levraut J, Gastaud P, Dolis C, Grimaud D. Use of i.v. insulin in well-controlled non-insulin-dependent diabetics undergoing major surgery. Br J Anesth. 1996;76:198–202.Google Scholar
  23. 23.
    Thorell A, Nygren J, Ljungqvist O. Insulin resistance: a marker of surgical stress. Curr Opin Clin Nutr Metab Care. 1999;2:69–78.CrossRefPubMedGoogle Scholar
  24. 24.
    Thorell A, Efendic S, Gutniak M, Haggmark T, Ljungqvist O. Development of postoperative insulin resistance is associated with the magnitude of operation. Eur J Surg. 1993;159:593–9.PubMedGoogle Scholar
  25. 25.
    Thorell A, Loftenius A, Andersson B, Ljungqvist O. Postoperative insulin resistance and circulating concentrations of stress hormones and cytokines. Clin Nutr. 1996;15:75–9.CrossRefPubMedGoogle Scholar
  26. 26.
    Saitoh Y, Hattori H, Sanbe N, Nakajima H, Akatu M, Murakawa M. Delayed recovery of vecuronium neuromuscular block in diabetic patients during sevoflurane anesthesia. Can J Anesth. 2005;52:467–73.CrossRefPubMedGoogle Scholar
  27. 27.
    Saitoh Y, Kaneda K, Hattori H, Nakajima H, Murakawa M. Monitoring of neuromuscular block after administration of vecuronium in patients with diabetes mellitus. Br J Anesth. 2003;90:480–6.CrossRefGoogle Scholar
  28. 28.
    Saitoh Y, Hattori H, Sanbe N, Nakajima H, Akatu M, Murakawa M. Reversal of vecuronium with neostigmine in patients with diabetes mellitus. Anaesthesia. 2004;59:750–4.CrossRefPubMedGoogle Scholar
  29. 29.
    Firriolo FJ, Miller CS, Rhodus NL. Perioperative management of diabetic patients. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2007;103:731–7.CrossRefGoogle Scholar
  30. 30.
    Simpson AK, Levy N, Hall GM. Peri-operative IV fluids in diabetic patients—don’t forget the salt. Anaesthesia. 2008;63:1043–5.CrossRefPubMedGoogle Scholar
  31. 31.
    Thomas DJ, Alberti KG. Hyperglycemic effects of Hartmann’s solution during surgery in patients with maturity onset diabetes. Br J Anaesth. 1978;50:185–8.CrossRefPubMedGoogle Scholar
  32. 32.
    Hall GM. Management of diabetes during surgery: 30 yr of the Alberti regimen. Anaesthesia. 2009;103:789–91.CrossRefGoogle Scholar
  33. 33.
    Arrowsmith JE, Grocott HP, Reves JG, Newman MF. Central nervous system complications of cardiac surgery. Br J Anaesth. 2000;84:378–93.PubMedGoogle Scholar
  34. 34.
    Tao LS, Mackenzie CR, Charlson ME. Predictors of postoperative complications in the patient with diabetes mellitus. J Diabetes Complications. 2008;22:24–8.CrossRefPubMedGoogle Scholar
  35. 35.
    Bentsen N, Larsen BO, Lassin NA. Chronically impaired autoregulation of cerebral blood flow in long-term diabetics. Stroke. 1975;6:497–502.PubMedGoogle Scholar
  36. 36.
    Griffith DNW, Saimbi S, Lewis C, Tolfree S, Betteridge DJ. Abnormal cerebrovascular carbon dioxide reactivity in people with diabetes. Diabetic Med. 1987;4:217–20.CrossRefPubMedGoogle Scholar
  37. 37.
    Dandona P, James IM, Woollard ML, Newbury P, Beckett AG. Instability of cerebral blood-flow in insulin-dependent diabetics. Lancet. 1979;8:1203–5.CrossRefGoogle Scholar
  38. 38.
    Rodrguez G, Nobili F, Celestino MA, Francione S, Gulli G, Hassan K, Marenco S, Rosadini G, Cordera R. Regional cerebral blood flow and cerebrovascular reactivity in IDDM. Diabetes Care. 1993;16:462–8.CrossRefGoogle Scholar
  39. 39.
    Pelligrino DA, Albrecht RF. Chronic hyperglycemic diabetes in the rat is associated with a selective impairment of cerebral vasodilatory response. J Cereb Blood Flow Metabol. 1991;11:667–77.Google Scholar
  40. 40.
    Croughwell N, Lyth M, Quill TJ, Newman M, Greeley WJ, Smith LR, Reves JG. Diabetic patients have abnormal cerebral autoregulation during cardiopulmonary bypass. Circulation. 1990;82(Suppl IV):407–12.Google Scholar
  41. 41.
    Kadoi Y, Saito S, Yoshikawa D, Goto F, Fujita N, Kunimoto F. Increasing mean arterial pressure has no effect on jugular venous oxygen saturation in insulin-dependent patients during tepid cardiopulmonary bypass. Anesth Analg. 2002;94:1395–401.CrossRefPubMedGoogle Scholar
  42. 42.
    Kawata R, Nakakimura K, Matsumoto M, Kawai K, Kunihiro M, Sakabe T. Cerebrovascular CO2 reactivity during anesthesia in patients with diabetes mellitus and peripheral vascular disease. Anesthesiology. 1998;89:887–93.CrossRefPubMedGoogle Scholar
  43. 43.
    Sieber FE, Brown PR, Wu Y, Koehler RC, Traystman RJ. Cerebral blood flow responsivity to CO2 in anesthetized chronically diabetic dogs. Am J Physiol. 1993;264:H1069–75.PubMedGoogle Scholar
  44. 44.
    Kadoi Y, Hinohara H, Kunimoto F, Saito S, Ide M, Hiraoka H, Kawahara F, Goto F. Diabetic patients have an impaired cerebral vasodilatory response to hypercapnia under propofol anesthesia. Stroke. 2003;34:2399–403.CrossRefPubMedGoogle Scholar
  45. 45.
    Stratton IM, Adler AI, Neil HAW, Matthews DR, Manley SE, Cull CA, Hadden D, Turner RC, Holman RR. Association of glycaemia with macrovascular and microvascular complications of type 2 diabetes (UKPDS 35): prospective observational study. BMJ. 2000;321:405–12.CrossRefPubMedGoogle Scholar
  46. 46.
    Klein R, Klein BEK, Moss SE, Davis MD, Demets DL. Glycosylated hemoglobin predicts the incidence and progression of diabetic retinopathy. JAMA. 1988;260:2864–71.CrossRefPubMedGoogle Scholar
  47. 47.
    Pallas F, Larson DF. Cerebral blood flow in the diabetic patient. Perfusion. 1996;11:363–70.CrossRefPubMedGoogle Scholar
  48. 48.
    Kadoi Y, Takahashi K, Saito S, Goto F. The comparative effects of sevoflurane versus isoflurane on cerebrovascular carbon dioxide reactivity in patients with diabetes mellitus. Anesth Analg. 2006;103:168–72.CrossRefPubMedGoogle Scholar
  49. 49.
    Kadoi Y, Goto F. Effects of nicardipine-induced hypotension on cerebrovascular carbon dioxide reactivity in patients with diabetes mellitus under sevoflurane anesthesia. J Anesth. 2007;21:125–30.CrossRefPubMedGoogle Scholar
  50. 50.
    Gur AY, Bova I, Bornstein NM. Is impaired cerebral vasomotor reactivity a predictive factor of stroke in asymptomatic patients? Stroke. 1996;27:2188–90.PubMedGoogle Scholar
  51. 51.
    Kessler C, Junge HM, Walker ML, Busack R, Albrecht DM, Ackeren KV. Reduced cerebral vasomotor reactivity as an indicator of postoperative confusion. Anaesthesia. 1997;52:433–7.CrossRefPubMedGoogle Scholar
  52. 52.
    Peleg AY, Weerarathna T, McCarthy JS, Davis TME. Common infections in diabetes: pathogenesis, management and relationship to glycemic control. Diabetes Metab Res Rev. 2007;23:3–13.CrossRefPubMedGoogle Scholar
  53. 53.
    Mowat AG, Baum J. Chemotaxis of polymorphonuclear leukocytes from patients with diabetes mellitus. New Engl J Med. 1971;284:621–7.CrossRefPubMedGoogle Scholar
  54. 54.
    Bagdade JD, Root RK, Bulger RJ. Impaired leukocyte function in patients with poorly controlled diabetes. Diabetes. 1974;23:9–15.PubMedGoogle Scholar
  55. 55.
    Rassias AJ, Marrin CAS, Arruda J, Whalen PK, Beach M, Yeager MP. Insulin infusion improves neutrophil function in diabetic cardiac surgery patients. Anesth Analg. 1999;88:1011–6.CrossRefPubMedGoogle Scholar
  56. 56.
    Furnary AP, Zerr KJ, Grunkemeier GL, Starr A. Continuous intravenous insulin infusion reduces the incidence of deep sternal wound infection in diabetic patients after cardiac surgical procedures. Ann Thorac Surg. 1999;67:352–60.CrossRefPubMedGoogle Scholar
  57. 57.
    Schmeltz LR, DeSantis AJ, Thiyagarajan V, Schmidt K, O’Shea-Mahler E, Johnson D, Henske J, McCarthy PM, Gleason TG, McGee EC, Molitch ME. Reduction of surgical mortality and morbidity in diabetic patients undergoing cardiac surgery with a combined intravenous and subcutaneous insulin glucose management strategy. Diabetes Care. 2007;30:823–8.CrossRefPubMedGoogle Scholar
  58. 58.
    Dungan K, Chapman J, Braithwaite SS, Buse J. Glucose measurement: confounding issues in setting targets for inpatient management. Diabetes Care. 2007;30:403–9.CrossRefPubMedGoogle Scholar

Copyright information

© Japanese Society of Anesthesiologists 2010

Authors and Affiliations

  1. 1.Department of Anesthesiology, Graduate School of MedicineGunma University HospitalMaebashiJapan

Personalised recommendations