Perioperative Care of Patients Using Wearable Diabetes Devices.

Publisher: Lippincott Williams & Wilkins Country of Publication: United States NLM ID: 1310650 Publication Model: Print-Electronic Cited Medium: Internet ISSN: 1526-7598 (Electronic) Linking ISSN: 00032999 NLM ISO Abbreviation: Anesth Analg Subsets: MEDLINE

Publication: 1998- : Baltimore, Md. : Lippincott Williams & Wilkins
Original Publication: Cleveland, International Anesthesia Research Society.

Perioperative Care*/methods ; Perioperative Care*/instrumentation ; Insulin Infusion Systems* ; Wearable Electronic Devices* ; Blood Glucose*/metabolism ; Blood Glucose*/analysis ; Diabetes Mellitus*/blood ; Diabetes Mellitus*/therapy ; Diabetes Mellitus*/drug therapy ; Blood Glucose Self-Monitoring*/instrumentation ; Insulin*/administration & dosage; Humans ; Hypoglycemic Agents/administration & dosage ; Hypoglycemic Agents/therapeutic use ; Equipment Design ; Glycemic Control/instrumentation

The increasing prevalence of diabetes mellitus has been accompanied by a rapid expansion in wearable continuous glucose monitoring (CGM) devices and insulin pumps. Systems combining these components in a "closed loop," where interstitial glucose measurement guides automated insulin delivery (AID, or closed loop) based on sophisticated algorithms, are increasingly common. While these devices' efficacy in achieving near-normoglycemia is contributing to increasing usage among patients with diabetes, the management of these patients in operative and procedural environments remains understudied with limited published guidance available, particularly regarding AID systems. With their growing prevalence, practical management advice is needed for their utilization, or for the rational temporary substitution of alternative diabetes monitoring and treatments, during surgical care. CGM devices monitor interstitial glucose in real time; however, there are potential limitations to use and accuracy in the perioperative period, and, at the present time, their use should not replace regular point-of-care glucose monitoring. Avoiding perioperative removal of CGMs when possible is important, as removal of these prescribed devices can result in prolonged interruptions in CGM-informed treatments during and after procedures, particularly AID system use. Standalone insulin pumps provide continuous subcutaneous insulin delivery without automated adjustments for glucose concentrations and can be continued during some procedures. The safe intraoperative use of AID devices in their hybrid closed-loop mode (AID mode) requires the CGM component of the system to continue to communicate valid blood glucose data, and thus introduces the additional need to ensure this portion of the system is functioning appropriately to enable intraprocedural use. AID devices revert to non-AID insulin therapy modes when paired CGMs are disconnected or when the closed-loop mode is intentionally disabled. For patients using insulin pumps, we describe procedural factors that may compromise CGM, insulin pump, and AID use, necessitating a proactive transition to an alternative insulin regimen. Procedure duration and invasiveness is an important factor as longer procedures increase the risk of stress hyperglycemia, tissue malperfusion, and device malfunction. Whether insulin pumps should be continued through procedures, or substituted by alternative insulin delivery methods, is a complex decision that requires all parties to understand potential risks and contingency plans relating to patient and procedural factors. Currently available CGMs and insulin pumps are reviewed, and practical recommendations for safe glycemic management during the phases of perioperative care are provided.
Competing Interests: Conflicts of Interest: See Disclosures at the end of the article.
(Copyright © 2024 International Anesthesia Research Society.)

Sudhakaran S, Surani SR. Guidelines for perioperative management of the diabetic patient. Surg Res Pract. 2015;2015:284063.
Duggan EW, Carlson K, Umpierrez GE. Perioperative hyperglycemia management: an update. Anesthesiology. 2017;126:547–560.
Seidelman JL, Mantyh CR, Anderson DJ. Surgical site infection prevention: a review. JAMA. 2023;329:244–252.
Pfeifer KJ, Selzer A, Mendez CE, et al. Preoperative management of endocrine, hormonal, and urologic medications: Society for Perioperative Assessment and Quality Improvement (SPAQI) consensus statement. Mayo Clin Proc. 2021;96:1655–1669.
Rajan N, Duggan EW, Abdelmalak BB, et al. Society for Ambulatory Anesthesia Updated Consensus Statement on Perioperative Blood Glucose Management in adult patients with diabetes mellitus undergoing ambulatory surgery. Anesth Analg. Published online March 22, 2024. doi:10.1213/ANE.0000000000006791. (PMID: 10.1213/ANE.0000000000006791)
Centre for Perioperative Care. Academy of Royal Medical Colleges. Guideline for perioperative care for people with diabetes mellitus undergoing elective and emergency surgery. Accessed April 8, 2024. https://cpoc.org.uk/sites/cpoc/files/documents/2021-03/CPOC-Diabetes-Guideline2021_0.pdf .
Nathan DM, Genuth S, Lachin J, et al.; Diabetes Control and Complications Trial Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med. 1993;329:977–986.
Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). UK Prospective Diabetes Study (UKPDS) Group. Lancet. 1998;352:837–853.
Karakus KE, Akturk HK, Alonso GT, Snell-Bergeon JK, Shah VN. Association between diabetes technology use and glycemic outcomes in adults with type 1 diabetes over a decade. Diabetes Care. 2023;46:1646–1651.
Trief PM, Cibula D, Rodriguez E, Akel B, Weinstock RS. Incorrect insulin administration: a problem that warrants attention. Clin Diabetes. 2016;34:25–33.
van den Boom L, Karges B, Auzanneau M, et al. Temporal trends and contemporary use of insulin pump therapy and glucose monitoring among children, adolescents, and adults with type 1 diabetes between 1995 and 2017. Diabetes Care. 2019;42:2050–2056.
Arunachalum S, Velado K, Vigersky RA, Cordero TL. Glycemic outcomes during real-world hybrid closed-loop system use by individuals with type 1 diabetes in the united states. J Diabetes Sci Technol. 2022;17:951–958.
Ebekozien O, Mungmode A, Sanchez J, et al. Longitudinal trends in glycemic outcomes and technology use for over 48,000 people with type 1 diabetes (2016-2022) from the T1D exchange quality improvement collaborative. Diabetes Technol Ther. 2023;25:765–773.
Jendle J, Reznik Y. Use of insulin pumps and closed-loop systems among people living with diabetes: A narrative review of clinical and cost-effectiveness to enable access to technology and meet the needs of payers. Diabetes Obes Metab. 2023;25(Suppl 2):21–32.
Basu S, Yudkin JS, Kehlenbrink S, et al. Estimation of global insulin use for type 2 diabetes, 2018-30: a microsimulation analysis. Lancet Diabetes Endocrinol. 2019;7:25–33.
Hirsch IB, McGill JB. Role of insulin in management of surgical patients with diabetes mellitus. Diabetes Care. 1990;13:980–991.
Committee ADAPP. 7. Diabetes technology: standards of care in diabetes—2024. Diabetes Care. 2023;47(suppl_1):S126–S144.
Yeh T, Yeung M, Mendelsohn Curanaj FA. Managing patients with insulin pumps and continuous glucose monitors in the hospital: to wear or not to wear. Curr Diab Rep. 2021;21:7.
Bergenstal RM, Beck RW, Close KL, et al. Glucose management indicator (GMI): a New term for estimating A1C from continuous glucose monitoring. Diabetes Care. 2018;41:2275–2280.
Eversense E3. Eversense continuous glucose monitoring system. Accessed May 5, 2023. https://www.ascensiadiabetes.com/eversense/#get-started .
Markov AM, Krutilova P, Cedeno AE, McGill JB, McKee AM. Interruption of CGM: frequency and adverse consequences. J Diabetes Sci Technol. Published online February 23, 2023. doi:10.1177/19322968231156572. (PMID: 10.1177/19322968231156572)
McKee AM, Yancey AM, Zhang RM, McGill JB. The nuances surrounding insulin prescribing. Clin Diabetes. 2023;41:411–419.
Mensh BD, Wisniewski NA, Neil BM, Burnett DR. Susceptibility of interstitial continuous glucose monitor performance to sleeping position. J Diabetes Sci Technol. 2013;7:863–870.
Idi E, Manzoni E, Sparacino G, Del Favero S. Data-driven supervised compression artifacts detection on continuous glucose sensors. Annu Int Conf IEEE Eng Med Biol Soc. 2022;2022:1145–1148.
Perez-Guzman MC, Duggan E, Gibanica S, et al. Continuous glucose monitoring in the operating room and cardiac intensive care unit. Diabetes Care. 2021;44:e50–e52.
Price CE, Fanelli JE, Aloi JA, et al. Feasibility of intraoperative continuous glucose monitoring: An observational study in general surgery patients. J Clin Anesth. 2023;87:111090.
E3 E. Safety information: MRI safety information. Accessed December 6, 2023. https://www.ascensiadiabetes.com/eversense/safety-info/ .
Spanakis EK, Levitt DL, Siddiqui T, et al. The effect of continuous glucose monitoring in preventing inpatient hypoglycemia in general wards: the glucose telemetry system. J Diabetes Sci Technol. 2017;12:20–25.
Singh LG, Satyarengga M, Marcano I, et al. Reducing inpatient hypoglycemia in the general wards using real-time continuous glucose monitoring: the glucose telemetry system, a randomized clinical trial. Diabetes Care. 2020;43:2736–2743.
Korytkowski MT, Muniyappa R, Antinori-Lent K, et al. Management of hyperglycemia in hospitalized adult patients in non-critical care settings: an endocrine society clinical practice guideline. J Clin Endocrinol Metabolism. 2022;107:2101–2128.
Committee ADAPP. 16. Diabetes care in the hospital: standards of medical care in diabetes—2022. Diabetes Care. 2021;45(suppl_1):S244–S253.
Committee ADAPP. 7. Diabetes technology: standards of medical care in diabetes—2022. Diabetes Care. 2021;45(suppl_1):S97–S112.
Partridge H, Perkins B, Mathieu S, Nicholls A, Adeniji K. Clinical recommendations in the management of the patient with type 1 diabetes on insulin pump therapy in the perioperative period: a primer for the anaesthetist. Br J Anaesth. 2016;116:18–26.
Sreedharan R, Khanna S, Shaw A. Perioperative glycemic management in adults presenting for elective cardiac and non-cardiac surgery. Perioper Med (Lond). 2023;12:13.
Martin LD, Hoagland MA, Rhodes ET, Wolfsdorf JI, Hamrick JL; Society for Pediatric Anesthesia Quality and Safety Committee Diabetes Workgroup. Perioperative management of pediatric patients with type 1 diabetes mellitus, updated recommendations for anesthesiologists. Anesth Analg. 2020;130:821–827.
Long MT, Coursin DB, Rice MJ. Perioperative considerations for evolving artificial pancreas devices. Anesth Analg. 2019;128:902–906.
Dominguez-Riscart J, Buero-Fernandez N, Garcia-Zarzuela A, Marmolejo-Franco FA, Perez-Guerrero AC, Lechuga-Sancho AM. Hybrid closed-loop system achieves optimal perioperative glycemia in a boy with type 1 diabetes: a case report. Front Pediatr. 2021;9:625390.
Herzig D, Suhner S, Roos J, et al. Perioperative fully closed-loop insulin delivery in patients undergoing elective surgery: an open-label, randomized controlled trial. Diabetes Care. 2022;45:2076–2083.
Kim YC, Wolf RM, Busin KM, Vanderhoek SM. Perioperative maintenance of hybrid closed loop insulin pump systems in youth with type 1 diabetes mellitus: a case series. Paediatr Anaesth. 2023;33:862–867.
Seget S, Wlodarczyk J, Lutogniewska W, Rusak E, Drozdz M, Jarosz-Chobot P. The use of a hybrid closed-loop system for glycemic control in two pediatric patients with type 1 diabetes undergoing minor surgery. Healthcare (Basel). 2023;11:587.
Avari P, Lumb A, Flanagan D, et al. Continuous glucose monitoring within hospital: a scoping review and summary of guidelines from the Joint British Diabetes Societies for inpatient care. J Diabetes Sci Technol. 2023;17:611–624.
Templer S. Closed-loop insulin delivery systems: past, present, and future directions. Front Endocrinol (Lausanne). 2022;13:919942.
Silva JD, Lepore G, Battelino T, et al. Real-world performance of the MiniMed 780G system: first report of outcomes from 4120 users. Diabetes Technol Ther. 2022;24:113–119.
U.S. Food and Drug Administration FDA Summary of Safety and Effectiveness Data. The U.S. Food and Drug Administration. Accessed June 7, 2024. https://www.accessdata.fda.gov/cdrh_docs/pdf16/p160017b.pdf .
Cruz P, Tobin GS. Inpatient Diabetes. The Washington Manual Subspecialty Consult Series. Endocrinology Subspecialty Consult. Fourth Edition. TJ Baranski, JB McGill, JM Silverstein (eds). 2018. Wolters Kluwer/Lippincott Williams & Wilkins, Philadelphia, PA.
Kitabchi AE, Umpierrez GE, Miles JM, Fisher JN. Hyperglycemic crises in adult patients with diabetes. Diabetes Care. 2009;32:1335–1343.

0 (Blood Glucose)
0 (Insulin)
0 (Hypoglycemic Agents)

Date Created: 20240624 Date Completed: 20241216 Latest Revision: 20241216

20241217

10.1213/ANE.0000000000007115

38913575