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Blood glucose level to cancel cataract surgery

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coffeebythelake

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Thoughts on this? What would be your BG range and cut-offs?

Recently I cancelled one whose BG was 450-500 mg/dL. Pt claimed to be compliant with all her diabetic medications. Talked to her PCP and found out she was lying and that she actually ran out of her humalog a month ago. No recent A1c.. given the hx I can assume her BG in the 400-500's range for the past month. Not the healthiest patient either, with CHF exacerbation in the last 3 months, known CAD, morbidly obese. Known history of non-compliance and a "difficult patient" according to PCP. For me it was an easy call to cancel, although I did tinker with the idea of correcting the BG with insulin and doing the case, with close follow-up.

Maybe I'm being too conservative (doubt it), but I've been burned before by a patient whose BG was 400's, was talked into doing the case by the ophthamologist who said the cataracts were so bad that it wasn't really elective and that she'll "make sure" the patient follows up. Well that patient never showed up for her postop ophtho visit or follow-up with her PCP, unreachable by phone, until nearly a month later. Quite exasperating to everyone involved (except the patient it would seem!)

There isn't a lot of high quality evidence out there about glycemic control and low-risk surgery with sedation and local. Most concerns relating to glyemic control relate to worsening BG from surgical stress, infection risk, poor wound healing, and more long-term health effects. This may or may not be an issue with cataract surgery, particularly if it is an uncomplicated one (e.g., not involving heavy sedation or general anesthesia). I think what is clear is that if the patient had severe metabolic derangements, in DKA or HHS they shouldn't be getting cataract surgery, but this represents an extreme physiologic state and I doubt anyone would argue against this. The other recommendations that are available are more opinion and surveys that leave quite a range of grey area. What I was able to find was a survey of clinician practices from Kumar et al., 2016: "In the absence of higher level evidence, survey of practices may influence the current opinion about perioperative glycaemic control for cataract surgery. A cross-sectional self-administered questionnaire was obtained from 129 ophthalmologists and ana esthetists,29 a blood glucose threshold concentration 17 mmol L1 (306 mg dL1 ) prompted the majority of doctors (86–93.8%) to adopt a treat-and-defer strategy, and a threshold of 23 mmol L1 (414 mg dL1 ) prompted most (86%–96.9%) to cancel the cataract surgery. Survey respondents were found to be more concerned about intraoperative hyperglycaemia than hypoglycaemia."

Personally, I consider patient comorbidities (but honestly no diabetic patient with such horrible BG are "healthy"), non-compliance issues, and whether they have close follow up scheduled to manage their BG (and whether I believe they will actually go to them).
 
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nimbus

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I can't see myself canceling a cataract


I’ve cancelled one in my career. I was at freestanding surgery center and the preop vitals showed o2sat in the mid 80s. Realized patient would not meet discharge criteria postop. Called an ambulance for trip to ER instead.
 
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coffeebythelake

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I’ve cancelled one in my career. I was at freestanding surgery center and the preop vitals showed o2sat in the mid 80s. Realized patient would not meet discharge criteria postop. Called an ambulance for trip to ER instead.

I think I've cancelled 2 or 3 in my career. Maybe I am being too conservative. ?
 
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nimbus

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I think I've cancelled 2 or 3 in my career. Maybe I am being too conservative. ?


Generally if they can lie flat for 15min without moving, they can have cataract surgery. Too bad we check those pesky vitals and blood sugars;)
 
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DocMcCoy

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Patients (and PCPs and surgeons) need to be held accountable somewhere in the pipeline prior to the OR for elective cases. I would have cancelled. Or the institution can stop checking vitals and sugars preop or they don’t want me to do anything.
 
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OneFellSwoop

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Me:
Are you actively having acute chest pain?
Do you have new onset dyspnea and can’t lay flat?
Are you having stroke symptoms?

Patient: No
Me: ok, good to go!
 

vector2

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My personal philosophy is that if you're spry enough to get a haircut you're spry enough for cataract surgery.
 
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dantt

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Ophtho here. We cancel at bs> 400. Systolic > 200, diastolic > 100. Not really worth it for me or any of my colleagues to push it. May be different in more competitive markets where patient will go to somewhere else for surgery but not here. (Ironically those patients are almost standard surgeries no additional refractive fees. Many doctors I know have no interest in doing them.)
 
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DrOwnage

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Ophtho here. We cancel at bs> 400. Systolic > 200, diastolic > 100. Not really worth it for me or any of my colleagues to push it. May be different in more competitive markets where patient will go to somewhere else for surgery but not here. (Ironically those patients are almost standard surgeries no additional refractive fees. Many doctors I know have no interest in doing them.)
If I had a nickel for how many cataracts I've done in patients with BPs over 200... I feel like 25% of them have BPs in the 190s, then they settle down 30-40 systolic after some versed. I don't give BP much consideration for a cataract unless the patient is symptomatic.
 
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nimbus

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If I had a nickel for how many cataracts I've done in patients with BPs over 200... I feel like 25% of them have BPs in the 190s, then they settle down 30-40 systolic after some versed. I don't give BP much consideration for a cataract unless the patient is symptomatic.


What symptoms? Headache? Chest pain?
 
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Southpaw

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Ophtho here. We cancel at bs> 400. Systolic > 200, diastolic > 100. Not really worth it for me or any of my colleagues to push it. May be different in more competitive markets where patient will go to somewhere else for surgery but not here. (Ironically those patients are almost standard surgeries no additional refractive fees. Many doctors I know have no interest in doing them.)

With your patient population I’d think that would lead to a pretty high day of surgery cancellation rate. The older folks can come in with some sky high BPs.
 

caligas

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Thoughts on this? What would be your BG range and cut-offs?

Recently I cancelled one whose BG was 450-500 mg/dL. Pt claimed to be compliant with all her diabetic medications. Talked to her PCP and found out she was lying and that she actually ran out of her humalog a month ago. No recent A1c.. given the hx I can assume her BG in the 400-500's range for the past month. Not the healthiest patient either, with CHF exacerbation in the last 3 months, known CAD, morbidly obese. Known history of non-compliance and a "difficult patient" according to PCP. For me it was an easy call to cancel, although I did tinker with the idea of correcting the BG with insulin and doing the case, with close follow-up.

Maybe I'm being too conservative (doubt it), but I've been burned before by a patient whose BG was 400's, was talked into doing the case by the ophthamologist who said the cataracts were so bad that it wasn't really elective and that she'll "make sure" the patient follows up. Well that patient never showed up for her postop ophtho visit or follow-up with her PCP, unreachable by phone, until nearly a month later. Quite exasperating to everyone involved (except the patient it would seem!)

There isn't a lot of high quality evidence out there about glycemic control and low-risk surgery with sedation and local. Most concerns relating to glyemic control relate to worsening BG from surgical stress, infection risk, poor wound healing, and more long-term health effects. This may or may not be an issue with cataract surgery, particularly if it is an uncomplicated one (e.g., not involving heavy sedation or general anesthesia). I think what is clear is that if the patient had severe metabolic derangements, in DKA or HHS they shouldn't be getting cataract surgery, but this represents an extreme physiologic state and I doubt anyone would argue against this. The other recommendations that are available are more opinion and surveys that leave quite a range of grey area. What I was able to find was a survey of clinician practices from Kumar et al., 2016: "In the absence of higher level evidence, survey of practices may influence the current opinion about perioperative glycaemic control for cataract surgery. A cross-sectional self-administered questionnaire was obtained from 129 ophthalmologists and ana esthetists,29 a blood glucose threshold concentration 17 mmol L1 (306 mg dL1 ) prompted the majority of doctors (86–93.8%) to adopt a treat-and-defer strategy, and a threshold of 23 mmol L1 (414 mg dL1 ) prompted most (86%–96.9%) to cancel the cataract surgery. Survey respondents were found to be more concerned about intraoperative hyperglycaemia than hypoglycaemia."

Personally, I consider patient comorbidities (but honestly no diabetic patient with such horrible BG are "healthy"), non-compliance issues, and whether they have close follow up scheduled to manage their BG (and whether I believe they will actually go to them).
Regardless of whether case is done, at what point does this patient need admission for severe hyperglycemia? BG 450-500, might they not have ketones, acidemia etc?
 
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D P356

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I think I cancelled the anesthetic on a cataract surgery because pt still had residual dip in their mouth, on tongue and between teeth.
Pt was mad.
I’m not cancelling a case, I’m cancelling an anesthetic for an elective case requiring minimal sedation. Probably overly conservative, but I’m not the one that didn’t follow preop directions in this event.

Had a busy Ortho that I delayed a case on as BG was 300s. I told surgeon about giving insulin and waiting for acceptable level (which pt was probably hyperglycemic that night and beyond). When I got pushback I asked when he wanted to schedule the I and D/washout.

Perioperatively my group has a quality metric for treating BG>180. Some would let it slide elsewhere. What the patient does at home is up to them.

We get paid to do cases, not cancel them.
 
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coffeebythelake

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No because who cares? I wouldn't check anything on a cataract surgery
They will be in your center 2 hours max

Interesting thoughts. If you never checked it, it is out of sight out of mind. But the BG was checked and it was sky high. Are you not compelled now to respond differently given this significantly abnormal result?

Perhaps we shouldn't even check NPO status on these cataract patients? I mean the likelihood of aspiration is probably near zero when your anesthetic is local with some anxiolysis..
 
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Interesting thoughts. If you never checked it, it is out of sight out of mind. But the BG was checked and it was sky high. Are you not compelled now to respond differently given this significantly abnormal result?

Perhaps we shouldn't even check NPO status on these cataract patients? I mean the likelihood of aspiration is probably near zero when your anesthetic is local with some anxiolysis..

If I see a high glucose yeah i'll tell the nurse to give a few units but do I care? They live there constantly, nothing I do will change their short or long term prognosis.

I have had a few cataract patients that weren't npo according to the guidelines. Still proceeded.
 
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Gern Blansten

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Ophtho here. We cancel at bs> 400. Systolic > 200, diastolic > 100. Not really worth it for me or any of my colleagues to push it. May be different in more competitive markets where patient will go to somewhere else for surgery but not here. (Ironically those patients are almost standard surgeries no additional refractive fees. Many doctors I know have no interest in doing them.)
I think this is a reasonable approach although I have given a pass on the BP issue in the past. Cataracts are not that stressful for the patient, but I have colleagues who have had a couple of bad outcomes with them related to intraop ischemia, so they are not completely benign.
 
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hiyaman

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Pretty interesting array of responses here. If patient shows up with BG >400 it definitely prompts further worries of other metabolic derangements. I don't see how you can't cancel it as its a purely elective surgery. You can't possibly talk me into believing a cataract is ever more than elective.

If they can't take care of their diabetes then do they really deserve their cataracts to be done?
 
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kidthor

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Interesting thoughts. If you never checked it, it is out of sight out of mind. But the BG was checked and it was sky high. Are you not compelled now to respond differently given this significantly abnormal result?

Perhaps we shouldn't even check NPO status on these cataract patients? I mean the likelihood of aspiration is probably near zero when your anesthetic is local with some anxiolysis..
I don't know about y'all but on occasion we've converted to general for cataract and other optho MAC patients who just aren't flying well. It's rare maybe 1% or less, but it's not never. So I'd certainly be reluctant to ignore NPO guidelines.

As for the high glucose I'll ask the surgeon what they want to do and then document that we had the conversation. I don't think the elevated glucose will legitimately impact our anesthetic, if anything it'll impact post op care on the optho side. That and the quality of life improvement after getting the surgeon could arguably be more immediately important than fixing glycemic control. Also I'm wary in an outpatient setting to initiate insulin on someone who hasn't been on it before.

The best is if your institution has a cutoff for hyperglycemia and maybe A1C for outpatient procedures - that way you aren't introducing frustration with personnel variability. It's hard to justify, when written down, doing elective procedures on patients with glucose >300 or A1C of 9+ unless it's emergent or urgent. If the surgeon wants to actually argue on those cutoffs then that'll be on them, not you (if you have a written policy that they want to violate).
 
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sevoflurane

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isn’t cataract surgery where anesthesiologists go to die as they approach retirement? 😂

I don’t know if i’ve done one of those cases since residency. I know they are cash cows… but… i just don’t do them- good cases for the over 65 group of docs. 😎
 
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VA Hopeful Dr

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Regardless of whether case is done, at what point does this patient need admission for severe hyperglycemia? BG 450-500, might they not have ketones, acidemia etc?
If they're sick enough from that to need admission, they will look pretty sick generally speaking.

These people have usually been there for weeks/months/years. Its not healthy by any stretch, but its not usually acutely dangerous either barring a type 1 patient.
 
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anbuitachi

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its not just about if they can get thru the SURGERY. its also about post op ! how well do they heal, does BG of 500 increase complications post op and how likely is it to be further optimized? i can get a patient thru a cataract even if they are actively having a MI or a stroke. doesnt mean i should do the case.

too many anesthesiologists only think about what happens intraop not post op complications. thats supposed to be what helps differentiates us from CRNAs

i would 100% cancel this patient and send her to the ED.

also if something does happen medicolegally. how will you defend proceeding? i think you will get destroyed in court

isn’t cataract surgery where anesthesiologists go to die as they approach retirement? 😂

I don’t know if i’ve done one of those cases since residency. I know they are cash cows… but… i just don’t do them- good cases for the over 65 group of docs. 😎

according to the other cataract thread, they are mostly money losers
 
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nimbus

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Pretty interesting array of responses here. If patient shows up with BG >400 it definitely prompts further worries of other metabolic derangements. I don't see how you can't cancel it as its a purely elective surgery. You can't possibly talk me into believing a cataract is ever more than elective.

If they can't take care of their diabetes then do they really deserve their cataracts to be done?


Aside from bariatric surgery and maybe total joints, I know of no instance when patients need to “earn” or deserve their surgery.
 
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cchoukal

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As others have said, the dispo is the issue. An event during the case is extraordinarily unlikely, but fast-forward to post-op and now you're signing out a patient to home with a glucose of 450 or whatever. That would be hard to defend.
 
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its not just about if they can get thru the SURGERY. its also about post op ! how well do they heal, does BG of 500 increase complications post op and how likely is it to be further optimized? i can get a patient thru a cataract even if they are actively having a MI or a stroke. doesnt mean i should do the case.

too many anesthesiologists only think about what happens intraop not post op complications. thats supposed to be what helps differentiates us from CRNAs

i would 100% cancel this patient and send her to the ED.

also if something does happen medicolegally. how will you defend proceeding? i think you will get destroyed in court



according to the other cataract thread, they are mostly money losers

It's a cataract. Patient leaves as they came in and probably better than they were.
 

hiyaman

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Aside from bariatric surgery and maybe total joints, I know of no instance when patients need to “earn” or deserve their surgery.
What about any kind of transplant surgery? Alcoholic needs to stop drinking for their liver transplant. IVDU needs to stop using IV drugs to get their valve replaced etc. Lots of surgeons will not offer elective intervention if patient does not take care of themselves, have uncontrolled diabetes, heart disease, pulmonary disease etc.

Different story for life threatening or malignancy related interventions/surgeries
 
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Guillemot

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Once a lab is checked, it cant be ignored from a medico-legal standpoint. Anyway, I guess Id probably use 400 as a cutoff for a cataract, but as what was stated earlier in the tread its a bit of a soft call.
 
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Beeftenderloin

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Pretty interesting array of responses here. If patient shows up with BG >400 it definitely prompts further worries of other metabolic derangements. I don't see how you can't cancel it as its a purely elective surgery. You can't possibly talk me into believing a cataract is ever more than elective.

If they can't take care of their diabetes then do they really deserve their cataracts to be done?
But what if they can’t take care of their diabetes BECAUSE of the cataracts: that “metformin” they thought they were taking for the past month after they ran out of their Rx was actually their dead husbands metoprolol.

Plus side, she’s the only 85 year old for a cataract that day that isn’t hypertensive.
 
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nimbus

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What about any kind of transplant surgery? Alcoholic needs to stop drinking for their liver transplant. IVDU needs to stop using IV drugs to get their valve replaced etc. Lots of surgeons will not offer elective intervention if patient does not take care of themselves, have uncontrolled diabetes, heart disease, pulmonary disease etc.

Different story for life threatening or malignancy related interventions/surgeries


Good point. But organs are scarce. Lenses are not.
 
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Gern Blansten

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They just have to test negative like everybody else if it’s elective. For thrombectomies, fractures, trachs, and pegs, it’s not necessary.
It was a little bit tongue in cheek. I should have used something to signify sarcasm. Sorry.
 

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Why these cataract patients getting sedated?
 

nimbus

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The procedure can be done with nothing.


 
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coffeebythelake

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The procedure can be done with nothing.



Yes for certain patients and under certain circumstances. Having the appropriate expectations is a big part of it. And it certainly won't work for patients unable to lay flat, or unable to follow commands, or a myriad of other reasons. A no-sedative anesthetic will not work for many patients that we take care of at my practice.
 
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Hoya11

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Thoughts on this? What would be your BG range and cut-offs?

Recently I cancelled one whose BG was 450-500 mg/dL. Pt claimed to be compliant with all her diabetic medications. Talked to her PCP and found out she was lying and that she actually ran out of her humalog a month ago. No recent A1c.. given the hx I can assume her BG in the 400-500's range for the past month. Not the healthiest patient either, with CHF exacerbation in the last 3 months, known CAD, morbidly obese. Known history of non-compliance and a "difficult patient" according to PCP. For me it was an easy call to cancel, although I did tinker with the idea of correcting the BG with insulin and doing the case, with close follow-up.

Maybe I'm being too conservative (doubt it), but I've been burned before by a patient whose BG was 400's, was talked into doing the case by the ophthamologist who said the cataracts were so bad that it wasn't really elective and that she'll "make sure" the patient follows up. Well that patient never showed up for her postop ophtho visit or follow-up with her PCP, unreachable by phone, until nearly a month later. Quite exasperating to everyone involved (except the patient it would seem!)

There isn't a lot of high quality evidence out there about glycemic control and low-risk surgery with sedation and local. Most concerns relating to glyemic control relate to worsening BG from surgical stress, infection risk, poor wound healing, and more long-term health effects. This may or may not be an issue with cataract surgery, particularly if it is an uncomplicated one (e.g., not involving heavy sedation or general anesthesia). I think what is clear is that if the patient had severe metabolic derangements, in DKA or HHS they shouldn't be getting cataract surgery, but this represents an extreme physiologic state and I doubt anyone would argue against this. The other recommendations that are available are more opinion and surveys that leave quite a range of grey area. What I was able to find was a survey of clinician practices from Kumar et al., 2016: "In the absence of higher level evidence, survey of practices may influence the current opinion about perioperative glycaemic control for cataract surgery. A cross-sectional self-administered questionnaire was obtained from 129 ophthalmologists and ana esthetists,29 a blood glucose threshold concentration 17 mmol L1 (306 mg dL1 ) prompted the majority of doctors (86–93.8%) to adopt a treat-and-defer strategy, and a threshold of 23 mmol L1 (414 mg dL1 ) prompted most (86%–96.9%) to cancel the cataract surgery. Survey respondents were found to be more concerned about intraoperative hyperglycaemia than hypoglycaemia."

Personally, I consider patient comorbidities (but honestly no diabetic patient with such horrible BG are "healthy"), non-compliance issues, and whether they have close follow up scheduled to manage their BG (and whether I believe they will actually go to them).

i would treat 400s
i would cancel anything starting with a 5

these diabetics are old and brittle, they skip their morning meds due to not being able to eat, they are dehydrated, and so they are way off their baseline.

as long as they are stable i give them insulin and fluid, recheck to ensure below 300, and then proceed. i give them instructions about what to do when they get home based on their situation.

because really this is what they need. they need to get the procedure done. getting there is hard. getting a covid test was hard. etc...

they need to be hydrated and have their sugar controlled acutely, while being advised about how to manage that sugar later that night after your interventions. i think i am capable of managing the sugar for a day and getting it done in these situations
 
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PlayToWin

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Those finger stick machines , especially found at surgi centers , become less reliable above 400. Once you start treating how long you keeping this person for ?? If you’re doing SQ insulin that takes forever to lower. Let’s say you treat and 3 hours later it still high. What now ? Too many variable that I don’t have time for especially at high volume surgi centers .

Also, if it’s a IDDM who didn’t take their meds as directed , it makes sense and we go ahead .

If patiet is not on insulin and now BS is high, something’s not right and they need optimization.
 
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pgg

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If they can't take care of their diabetes then do they really deserve their cataracts to be done?
Deserve ain't got nothing to do with it.

No, they aren't taking care of their diabetes. No, they won't ever take care of their diabetes.

But we can still help them not be blind. C'mon ... there's probably nothing at all anyone can do for these people in 10 minutes that can possibly rival the massive improvement in their quality of life when they can suddenly see again. Look for a way to say yes and do the case. Yeah, if someone drew labs for some reason, give some insulin. You can't ignore a fever after you've taken a temperature. But do the case.

If they're not NPO, by all means send them home to come back another day. The condition of "I ate breakfast" is something they can semi-reliably correct by next week.
 
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fakin' the funk

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Thoughts on this? What would be your BG range and cut-offs?

Recently I cancelled one whose BG was 450-500 mg/dL. Pt claimed to be compliant with all her diabetic medications. Talked to her PCP and found out she was lying and that she actually ran out of her humalog a month ago. No recent A1c.. given the hx I can assume her BG in the 400-500's range for the past month. Not the healthiest patient either, with CHF exacerbation in the last 3 months, known CAD, morbidly obese. Known history of non-compliance and a "difficult patient" according to PCP. For me it was an easy call to cancel, although I did tinker with the idea of correcting the BG with insulin and doing the case, with close follow-up.

Maybe I'm being too conservative (doubt it), but I've been burned before by a patient whose BG was 400's, was talked into doing the case by the ophthamologist who said the cataracts were so bad that it wasn't really elective and that she'll "make sure" the patient follows up. Well that patient never showed up for her postop ophtho visit or follow-up with her PCP, unreachable by phone, until nearly a month later. Quite exasperating to everyone involved (except the patient it would seem!)

There isn't a lot of high quality evidence out there about glycemic control and low-risk surgery with sedation and local. Most concerns relating to glyemic control relate to worsening BG from surgical stress, infection risk, poor wound healing, and more long-term health effects. This may or may not be an issue with cataract surgery, particularly if it is an uncomplicated one (e.g., not involving heavy sedation or general anesthesia). I think what is clear is that if the patient had severe metabolic derangements, in DKA or HHS they shouldn't be getting cataract surgery, but this represents an extreme physiologic state and I doubt anyone would argue against this. The other recommendations that are available are more opinion and surveys that leave quite a range of grey area. What I was able to find was a survey of clinician practices from Kumar et al., 2016: "In the absence of higher level evidence, survey of practices may influence the current opinion about perioperative glycaemic control for cataract surgery. A cross-sectional self-administered questionnaire was obtained from 129 ophthalmologists and ana esthetists,29 a blood glucose threshold concentration 17 mmol L1 (306 mg dL1 ) prompted the majority of doctors (86–93.8%) to adopt a treat-and-defer strategy, and a threshold of 23 mmol L1 (414 mg dL1 ) prompted most (86%–96.9%) to cancel the cataract surgery. Survey respondents were found to be more concerned about intraoperative hyperglycaemia than hypoglycaemia."

Personally, I consider patient comorbidities (but honestly no diabetic patient with such horrible BG are "healthy"), non-compliance issues, and whether they have close follow up scheduled to manage their BG (and whether I believe they will actually go to them).
Cancel a cataract if, and only if, the patient should go directly to the ED.

This counts.
 

fakin' the funk

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If I see a high glucose yeah i'll tell the nurse to give a few units but do I care? They live there constantly, nothing I do will change their short or long term prognosis.

I have had a few cataract patients that weren't npo according to the guidelines. Still proceeded.
I think this is meant to be bragging but it is actually quite sad
 
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gcc322

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Deserve ain't got nothing to do with it.

No, they aren't taking care of their diabetes. No, they won't ever take care of their diabetes.

But we can still help them not be blind. C'mon ... there's probably nothing at all anyone can do for these people in 10 minutes that can possibly rival the massive improvement in their quality of life when they can suddenly see again. Look for a way to say yes and do the case. Yeah, if someone drew labs for some reason, give some insulin. You can't ignore a fever after you've taken a temperature. But do the case.

If they're not NPO, by all means send them home to come back another day. The condition of "I ate breakfast" is something they can semi-reliably correct by next week.
I used to do a lot of cataracts. Early in my career the preop nurse asked about a 480 blood sugar. I ordered 10u regular IV insulin and delayed the case until blood sugar less than 300. 15 minutes later it was 220. 30 minutes 80. My thought was the machine was off but the nurse could have given the wrong dose. That was the last time I gave insulin preop.

The ambulatory center isn’t a treatment facility. If a patient doesn’t meet discharge criteria preop then they won’t meet it post op. I don’t give insulin for hyperglycemia, labetalol for htn, or reglan/famotidine for full stomachs like some I have seen.
 
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