Wearable diabetes devices
Myron Yaster MD and Samuel Vanderhoek MD
Wearable diabetes devices
Myron Yaster MD and Samuel Vanderhoek MD
Patients with type 1 diabetes mellitus (T1D) 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 automated insulin delivery (AID) systems, continuous glucose monitors (CGM), and hybrid closed-loop devices (HCLS) have increased dramatically over the last decade with improved patient outcomes.”1 When children (and adults) with type 1 diabetes who use these advanced diabetes technologies present for anesthesia do you know what to do? For a while 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 and recently authored a paper based on a survey of the members of the Society for Pediatric Anesthesia which revealed large gaps in knowledge of how to manage patients arriving to the operating rooms wearing these devices.2 Because this is definitely not an area of my expertise, I asked Sam to help me once again in today’s PAAD as he has in a previous PAAD (October 08, 2024 https://ronlitman.substack.com/p/navigating-advanced-diabetes-technologies-2dc . You can also find more information on this topic in an article in Open Anesthesia which is a free on-line resource that only requires a one time registration to access its articles. (Duggar B, Hoagland 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/ . Finally, there is an upcoming article in the journal Pediatric Anesthesia3 that we will be reviewing in an upcoming PAAD that also discusses many of these issues. Myron Yaster MD
Original article
Cruz P, McKee AM, Chiang HH, McGill JB, Hirsch IB, Ringenberg K, Wildes TS. Perioperative Care of Patients Using Wearable Diabetes Devices. Anesth Analg. 2025 Jan 1;140(1):2-12. doi: 10.1213/ANE.0000000000007115. Epub 2024 Jan 24. PMID: 38913575.
Long-term intensive insulin therapy is a cornerstone of treatment in type 1 diabetes. Over the past 2 decades, significant advances in diabetes technologies have transformed the landscape of diabetes care. These technologies include continuous glucose monitors (CGM), insulin pumps, and automated insulin delivery systems (AID). In AIDs, glucose data from the CGM are transmitted via Bluetooth technology to the insulin pump that autonomously adjusts rates of insulin delivery. These devices have been shown to be both safe and effective in adults and children. In today’s PAAD, Cruz et al “review evidence regarding wearable diabetes management devices in procedural patients.” In keeping with the PAAD’s mission of keeping our reviews to 5-6 minute reads we will highlight key points. We recommend reading the article in its entirety and using it and the other articles referenced below as a launching point for a more thorough discussion.
CGMs:
“Depending on the procedure site and patient positioning, individuals wearing CGM devices should be advised in advance whether they will be able to keep the device in place, and in what location. CGMs should be kept in place during the procedural period whenever possible for several reasons and is particularly relevant for patients using AID systems.”1 In general, CGMs are highly accurate, though there may be perioperative situations in which CGM glycemic data is less reliable, including device compression or use of electrocautery. As a result, while CGMs can be used perioperatively to guide treatment decisions, regular point-of-care glucose testing remains the gold standard and is mandatory.
Insulin pumps & AIDs:
Insulin pumps can be divided into 2 main categories: tubed pumps, where insulin infuses from a reservoir within the pump and runs through tubing to a subcutaneously inserted cannula, and tubeless pumps in which the reservoir and cannula are part of a single pod attached to the skin. Regardless of the pump’s physical design (tubed or tubeless), insulin pumps can deliver insulin using preset basal rates (“standalone pumps”) or with algorithmic technologies (“AID”) where CGM glycemic data is used to adjust rates of insulin delivery and even provide small correction doses. “AID systems revert to pre-set basal rates if CGM pairing is lost or glucose readings are not registered, thus transitioning to function as a standalone pump. If this occurs, backup programmed basal rates may not reflect current insulin requirements for a patient. Therefore, conversion of AID systems to non-AID mode in the periprocedural period, whether intentionally or by unanticipated loss of paired CGM function, may promote significant dysglycemia.”1
An excellent treatment algorithm from the paper is presented below. Whether or not insulin pumps should be maintained during an anesthetic, and in what mode an AID provides the safest and most optimal glycemic control, remains an area of ongoing research. There is a growing body of case reports indicating safe anesthetic management with maintenance of AIDs in exercise or activity modes that facilitate higher glycemic targets.6 Nevertheless, surgeries with anticipated hemodynamic lability, use of vasopressors or periods of hypothermia – all of which may compromise subcutaneous blood flow and insulin absorption – may prompt one to remove the insulin pump and start an intravenous insulin infusion. Additionally, "procedures where satisfactory device positioning may not be feasible; procedures where the device cannot be protected from contraindicated imaging/energies; or procedures where early postoperative device management by the patient will be compromised" may also favor pump removal. Regardless of whether the insulin pump is maintained or replaced with an IV infusion, a patient with insulin-dependent diabetes must always have a source of insulin on board.
Clear? Or clear as mud? While reviewing this paper, I (MY) was shocked at how little data and evidence-based recommendations actually exist for the pediatric population being treated with this wearable technology. Rather than bemoan this, we think this is an extraordinary opportunity for collaborative research amongst interested anesthesiologists under the Society for Pediatric Anesthesia’s Improvement Network (SPAIN). We need data from well-designed clinical trials rather than expert opinion. We are hoping that today’s PAAD will spur many of you to investigate the perioperative management of T1D and T2D. If you are interested in participating in such a research collaborative, drop Sam an email (svande20@jhmi.edu).
Send your thoughts and comments to Myron who will post in a Friday reader response.
PS from Myron: As I often do when reviewing this type of article, I checked my Pedi Crisis app version 2 to see what the app suggests for hyper or hypoglycemia with or without the use of CGMS and AID systems. And to my chagrin found nothing. Yet another opportunity!
References
1. Cruz P, McKee AM, Chiang HH, et al. Perioperative Care of Patients Using Wearable Diabetes Devices. Anesthesia and analgesia 2025;140(1):2-12. (In eng). DOI: 10.1213/ane.0000000000007115.
2. 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):884-886. (In eng). DOI: 10.1213/ane.0000000000007039.
3. Hoagland M, Duggar B, Hamrick J, Alonso GT, Martin L. Error traps in the perioperative management of children with type 1 diabetes. Paediatric anaesthesia 2024;34(1):19-27. (In eng). DOI: 10.1111/pan.14763.
4. Nathan DM, Genuth S, Lachin J, et al. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. The New England journal of medicine 1993;329(14):977-86. (In eng). DOI: 10.1056/nejm199309303291401.
5. 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. Anesthesia and analgesia 2024;139(3):459-477. (In eng). DOI: 10.1213/ane.0000000000006791.
6. 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. Paediatric anaesthesia 2023;33(10):862-867. (In eng). DOI: 10.1111/pan.14732.