Navigating Advanced Diabetes Technologies in Perioperative Practice
Myron Yaster MD and Samuel Vanderhoek MD
Patients with type 1 diabetes mellitus do not secrete endogenous insulin and require exogenous insulin at all times, even while fasting, to maintain euglycemia and prevent ketoacidosis. “The use of advanced diabetes technologies (ADT) in type 1 diabetes management—including insulin pumps, continuous glucose monitors (CGM), and hybrid closed-loop devices (HCLS) have increased dramatically over the last decade with improved patient outcomes.”1 When children with type-1 diabetes present for anesthesia with these advanced diabetes technologies do you know what to do? Pediatric anesthesiologist Dr. Samuel Vanderhoek of the Johns Hopkins University has been thinking about the perioperative management of diabetics and anesthesia provider knowledge, particularly of these new technologies for a while. In today’s PAAD, He and his colleagues “surveyed pediatric anesthesia providers to explore their familiarity and experience knowledge and experience with these new advanced devices .”1 Because this is definitely not an area of my expertise, I asked Sam to help me in today’s PAAD.
As you will see, the results of this survey study were pretty terrible. There are several relatively recent papers2-4 that discuss and review the management of type 1 diabetic patients and how to manage advanced diabetic technologies including a recent Open Anesthesia article to guide you in your practice. I recognize that not all of you have access to the articles and references we discuss in the PAAD. So, in today’s PAAD, I am also including an article from Open Anesthesia which is a free on-line resource that only requires a one time registration to access its articles. Hopefully, for those of you who need to get up to speed in using these technologies, these articles will help in filling in some of he gaps in your knowledge and thereby improve the care you provide to your patients. Myron Yaster MD
Research Letter
Vanderhoek SM, Sklar MB, Zeng Y, Prichett LM, Wolf RM. Navigating Advanced Diabetes Technologies in Perioperative Practice: A Survey of Pediatric Anesthesiologists. Anesth Analg. 2024 Oct 1;139(4):884-886. doi: 10.1213/ANE.0000000000007039. Epub 2024 Sep 4. PMID: 38995851.
Open Anesthesia
Duggar B, Hoadland M: Perioperative Management of Patients with Type 1 Diabetes Mellitus 08/15/2023
https://www.openanesthesia.org/keywords/perioperative-management-of-patients-with-type-1-diabetes-mellitus/
Today’s PAAD by Vanderhoek SM et al is based on an on-line survey of the members of the Society for Pediatric Anesthesia (n=3,541) that was sent via email in 2023. . “The survey consisted of 19 closed-ended, multiple-choice questions divided into 4 sections by concept.”4 While the survey had a low response rate (n=257 or 7.3%),and only 214 (6.0%) actually completed the survey, this is actually typical of many survey invitations sent through large distributions lists which are not individually targeted. Regardless, with such a low response rate, why did the journal publish this and why are we reviewing it in the PAAD?
Sometimes, you know or suspect that something is true even though you can’t prove it. The goal of surveys like this is to obtain a representative sample of respondents to identify gaps in education and awareness. And the results of this survey is something I (MY) have suspected for a long time. What did the authors find? Of survey respondents, only 52.3% reported receiving formal or informal education on ADT use while >75% reported having little or no knowledge of HCLS . Additionally, less than half were aware of hospital policies for patients with ADT and nearly all reported a desire to increase their knowledge of ADT. The survey included a 3-question knowledge assessment section on ADT; importantly, only 11.6% of respondents answered all 3 questions correctly. The study highlights the wide practice variations in managing children using ADT who require anesthesia, including not only how these devices are maintained but also strategies for glycemic control when they must be removed.
We suspect that many of you have, like the respondents to this survey, large lacunae in your knowledge of these new diabetes technologies and how to manage diabetes in this new world. I (MY) know I do. By highlighting this article, it is clear that additional resources and training are needed to streamline the safe perioperative use of these technologies. The references below and the Open Anesthesia article listed above might help many of you fill in your knowledge gaps.
Send your thoughts and comments to Myron who will post in a Friday reader response.
References
1. Vanderhoek SM, Sklar MB, Zeng Y, Prichett LM, Wolf RM. Navigating Advanced Diabetes Technologies in Perioperative Practice: A Survey of Pediatric Anesthesiologists. Anesthesia and analgesia 2024; 139(4): 884-6.
2. Martin LD, Hoagland MA, Rhodes ET, Wolfsdorf JI, Hamrick JL. Perioperative Management of Pediatric Patients With Type 1 Diabetes Mellitus, Updated Recommendations for Anesthesiologists. Anesthesia and analgesia 2020; 130(4): 821-7.
3. Kapellen T, Agwu JC, Martin L, et al. ISPAD clinical practice consensus guidelines 2022: Management of children and adolescents with diabetes requiring surgery. Pediatr Diabetes 2022; 23(8): 1468-77.
4. Vanderhoek SM, Moini A, Prichett L, Wolf RM. Practice patterns of perioperative insulin pump management in pediatric diabetes. Paediatric anaesthesia 2021; 31(7): 827-9.