How high is too high for blood sugar?

[Intubate]

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I'm preparing for oral boards, and asking myself, why? all the time...
One of my partners had a 48 yr old hypertensive type 2 diabetic for an abdominal hysterectomy who ran out of her oral hypoglycemic agents a week ago. Her blood sugar was 365. My partner cancelled her and told her to see her primary MD, get back on her meds, and come back.

I thought I probably would have treated with insulin, given some fluid, and done the case. But then I got to thinking, when would I NOT do the case? I think I need a good answer for that question, but I don't have one. I guess you could send labs to make sure a patient wasn't ketotic (if they were type 1) or hyperosmolar (type 2)? Never seen anyone do that, though.

Anyone?

 

[Planktonmd]

There is really no magic number, but good blood sugar control is desirable before elective surgery, and this means the closer to normal you can get the better.
Poorly controled blood sugar causes many problems ,as you know, including increased infection rate and delayed healing, in addition to a global increase in postoperative morbidity and mortality.
If the patient is medically optimized and compliant with hypoglycemics but still shows up with elevated blood sugar the day of surgery, then acute management might be ok, but 360 is too high and I would say a good personal number is 300.
So.. for the boards, any abnormal blood sugar needs to be addressed before elective surgery, and a full evaluation is needed including all the possible end organ complications of diabetes.
Now... real life is a little different as you know, and many times there are other factors that need to be considered, many of which have nothing to do with science or medicine.

 

[militarymd]

We routinely take patients with high glucoses (>350) who are asymptomatic to the OR.

It depends solely on the type of surgery you're having....low risk....intermediate....high risk.

I have a hand surgeon who does carpal tunnels in 2 minutes ..skin to skin...with a Bier Block....Less stress than taking a dump....Why on god's green earth would anyone delay that case for asymptomatic hyperglycemia.

A TAH....well...that depends on your surgeon....but we would take this patient back with our surgeons...1 hour case...100 cc blood loss....less than donating a unit of blood.

All that stuff you're reading about morbidity and mortality.....look at what surgeries they're having....

 

[Noyac]

I agree that it depends on the surgery and the surgeon. Just remember that they will be making urine like crazy and that they are most likely be dehydrated to start with.

 

[Planktonmd]

We routinely take patients with high glucoses (>350) who are asymptomatic to the OR.

It depends solely on the type of surgery you're having....low risk....intermediate....high risk.

I have a hand surgeon who does carpal tunnels in 2 minutes ..skin to skin...with a Bier Block....Less stress than taking a dump....Why on god's green earth would anyone delay that case for asymptomatic hyperglycemia.

A TAH....well...that depends on your surgeon....but we would take this patient back with our surgeons...1 hour case...100 cc blood loss....less than donating a unit of blood.

All that stuff you're reading about morbidity and mortality.....look at what surgeries they're having....

Militarymd
is this how you want him to answer on his oral boards?

 

[militarymd]

Militarymd
is this how you want him to answer on his oral boards?

I would and DID answer my boards in such a manner.

 

[DerekJeter]

I would and DID answer my boards in such a manner.

When are you taking them again?

 

[cfdavid]

I agree that it depends on the surgery and the surgeon. Just remember that they will be making urine like crazy and that they are most likely be dehydrated to start with.

osmotic diuresis?

 

[militarymd]

When are you taking them again?

😕

I passed them 10 years ago.....then I passed the CCM ones...

Are you trying to be funny?😕

 

[dhb]

I have a hand surgeon who does carpal tunnels in 2 minutes ..skin to skin

I agree with Mil but why do you need a Bier block for 2 min can't he do it under local? does he need the tourniquet?

 

[militarymd]

I agree with Mil but why do you need a Bier block for 2 min can't he do it under local? does he need the tourniquet?

he doesn't do local...and he needs a tourniquet anyways.

 

[Laurel123]

I'm preparing for oral boards, and asking myself, why? all the time...
One of my partners had a 48 yr old hypertensive type 2 diabetic for an abdominal hysterectomy who ran out of her oral hypoglycemic agents a week ago. Her blood sugar was 365. My partner cancelled her and told her to see her primary MD, get back on her meds, and come back.

I thought I probably would have treated with insulin, given some fluid, and done the case. But then I got to thinking, when would I NOT do the case? I think I need a good answer for that question, but I don't have one. I guess you could send labs to make sure a patient wasn't ketotic (if they were type 1) or hyperosmolar (type 2)? Never seen anyone do that, though.

Anyone?

I think it would depend on the case. I recently did a PHACO with a patient with her sugars in the 300's. She was completely asymptomatic and surgery is very low stress. She also was pretty young and didn't have anything else going on.

I probably would have gone on with the case too with a little insulin and fluid if I felt good about the surgeon and the patient felt like her baseline. For the boards however, I would probably say I would cancel. Elective surgery and nonoptimized disease... if I proceeded, they would keep making the patient sicker and sicker whereas cancelling is a defendable choice on the oral boards (patient is dehydrated, stress of surgery, fluid shifts during surgery..)

 

[militarymd]

...... Elective surgery and nonoptimized disease... if I proceeded, they would keep making the patient sicker and sicker whereas cancelling is a defendable choice on the oral boards (patient is dehydrated, stress of surgery, fluid shifts during surgery..)

I really don't like the word "optimized"......

What about a diabetic who shows up with a glucose of 100 mg/dl....but her HbA1c is 20......

Definitely NOT "optimized" from the ADA's recommendations on treatment of diabetes....

Should one cancel that case because the patient is not "optimized"?

 

[Laurel123]

I really don't like the word "optimized"......

What about a diabetic who shows up with a glucose of 100 mg/dl....but her HbA1c is 20......

Definitely NOT "optimized" from the ADA's recommendations on treatment of diabetes....

Should one cancel that case because the patient is not "optimized"?

I agree, it isn't a great word - I've just been practicing my oral boards with the Ho course, and they use the term to sort of summarize whether a patient is 'as good as they are going to get' and whether or not they need to be 'optimized' before surgery.

This is actually a pretty good board question.

 

[Gern Blansten]

I really don't like the word "optimized"......

Words I don't like:

Homunculus
Tartar
Hubris
Vituperation
Perfunctory
Curmudgeon
Masticate
🙂

 

[militarymd]

I agree, it isn't a great word - I've just been practicing my oral boards with the Ho course, and they use the term to sort of summarize whether a patient is 'as good as they are going to get' and whether or not they need to be 'optimized' before surgery.

This is actually a pretty good board question.

I use the phrase "This patient is medically ACCEPTABLE for surgery"

 

[militarymd]

I agree, it isn't a great word - I've just been practicing my oral boards with the Ho course, and they use the term to sort of summarize whether a patient is 'as good as they are going to get' and whether or not they need to be 'optimized' before surgery.

This is actually a pretty good board question.

So this begs the question.....do patients need to be "as good as they are going to get" for certain types of surgery?

A patient with known hypertension who comes to the OR with blood pressures 150/90....documented ...been that way for a year on single oral antihypertensive patient....for TAH....

Is this patient "as good as they are going to get"?

I think not....at least according to JNCVII....

Should we cancel?

 

[Noyac]

So this begs the question.....do patients need to be "as good as they are going to get" for certain types of surgery?

A patient with known hypertension who comes to the OR with blood pressures 150/90....documented ...been that way for a year on single oral antihypertensive patient....for TAH....

Is this patient "as good as they are going to get"?

I think not....at least according to JNCVII....

Should we cancel?

I haven't cancelled one for this yet.

Just as i didn't cancel the guy on 7 heart meds (if you count ASA and a statin a heart med) when he came in for his non-emergent small bowel resection with a BP of 190/85. But this is different, he isn't always 190/85. Just today.

Also didn't cancel the 73 yo lady with a pelvic mass who's ECG showed an MI in the past verified by the cardiologist and without a stress test. The last thing I wanted was the cards guys to cath her and put a stent in just b/4 surgery. They can do that **** after I am done with her. I put her to sleep and she went into some funky rhythm which varied from 130 to 80 within a matter of beats. i loaded her with metoprolol, lidocaine and 2gm Mg. She rapidly settled down to a rate 60's for the ret of the day. We have so much control of these pts that I hesitate to send then to cards without a great need.

 

[TIVA]

I have a hand surgeon who does carpal tunnels in 2 minutes ..skin to skin...with a Bier Block........

Wow, 2 minutes! And then you guys have to wait another 18 minutes before you can let the tourniquet down so the patient won't seize. That's great ... plenty of time for charting. 🙂

 

[Noyac]

Wow, 2 minutes! And then you guys have to wait another 18 minutes before you can let the tourniquet down so the patient won't seize. That's great ... plenty of time for charting. 🙂

Yeah, I'm not a fan of the beir block under any circumstance (I still use it from time to time). I had a surgeon that did the CTR in a matter of minutes as well. I would give about 5 to 10 cc of propofol and he would be done. He did use local.

 

[militarymd]

Wow, 2 minutes! And then you guys have to wait another 18 minutes before you can let the tourniquet down so the patient won't seize. That's great ... plenty of time for charting. 🙂

He runs 2 rooms....we set up...prep and drap while he is in the other room...talking to family ....see subsequent patients etc...

By the time he comes into the OR...the tq has been up for 10 minutes....

and who in the world waits 20 minutes before letting the tq down?

 

[dfk]

Also didn't cancel the 73 yo lady with a pelvic mass who's ECG showed an MI in the past verified by the cardiologist and without a stress test

hey noyac, do you remember when the previous MI was? in our institution, anyone within 3-6 months is borderline, and anytime after 6 months is fine. i am just wondering what other's parameters are. also, lack of stress test, is this common as well?

 

[militarymd]

hey noyac, do you remember when the previous MI was? in our institution, anyone within 3-6 months is borderline, and anytime after 6 months is fine. i am just wondering what other's parameters are. also, lack of stress test, is this common as well?

Goldman ....is sooooo...80's

 

[dfk]

Goldman ....is sooooo...80's

ok, good to know.. since i'm new to the profession, any thoughts as to when you would/would not cancel surgery post-MI, disregarding emergent?

 

[militarymd]

ok, good to know.. since i'm new to the profession, any thoughts as to when you would/would not cancel surgery post-MI, disregarding emergent?

After risk stratifcation....6 weeks....at the earliest or after completing your oral antiplatelet regimen


I think it is covered in the ACC guidelines on preop evaluation....or just in the general literature....I can't remember where.