Management of the Elderly Diabetic Patient During Anesthesia

Diabetes mellitus is frequently encountered in elderly patients who enter the hospital for surgery. The overwhelming majority of these patients have NIDDM. The diagnosis of NIDDM in elderly patients is difficult because the metabolism of a glucose load is progressively impaired during aging. The mechanism for this alteration is not completely clear, but insulin antagonism appears to be a major factor. The criteria recommended by the National Diabetes Data Group are useful in establishing the diagnosis.

The pathogenic influences in NIDDM include insulin deficiency, insulin resistance and accelerated hepatic glucose production. The pathogenesis of IDDM involves genetic, immunologic and viral etiologies.

The concerns of the anesthesiologist in caring for elderly patients with diabetes relate to the acute and chronic complications of the disease. Acute complications consist of diabetic ketoacidosis, hyperosmolar non-ketotic syndrome, lactic acidosis, hypoglycemia, infection and delayed wound healing. Chronic complications include retinopathy, nephropathy, neuropathy, cardiovascular disease and dermatologic abnormalities.

A thorough preoperative evaluation with correction of organ dysfunction and metabolic derangement to the extent possible is essential to the safe conduct of anesthesia. The choice of anesthetic technique is dependent upon many factors, but regional anesthesia, when feasible, is the preferred technique for the elderly diabetic. Regardless of the anesthetic technique selected, it is essential to carefully monitor and control blood glucose during the perioperative period in order to avoid the adverse effects of uncontrolled hyperglycemia or hypoglycemia.