Perioperative management of diabetes audit (POMODA)

Abstract

BackgroundSuboptimal perioperative management of diabetes is associated with postoperative morbidity and mortality. Australian healthcare providers should primarily be guided by the Australian Diabetes Society Perioperative Diabetes Management Guidelines in caring for the perioperative diabetic patient when local or state guidelines do not exist. MethodsA retrospective, single-center, quality improvement audit was conducted on diabetic patients aged ≥18 years undergoing surgical procedures at the Townsville University Hospital, Australia, over a 12-week period. Perioperative outcomes were analyzed to establish compliance with the guidelines. Secondary objectives analyzed outcomes for Indigenous and non-Indigenous Australian patients, and patients’ age. Results202 patients were reviewed. 53 (26%) had preoperative blood glucose levels (BGLs) measured hourly. Of the patients requiring intraoperative BGLs, 93% did not have BGLs hourly and 71% did not have any intraoperative BGL. 23 (11%) had hourly BGLs postoperatively. Average preoperative haemoglobin A1c (HbA1c) was 7.5%, above target, and not measured in 45% of patients. 16/42 (38%) on metformin having major surgery had it restated appropriately. 29/41 (71%) on Sodium-Glucose Cotransporter-2 (SGLT2) inhibitors did not have a perioperative ketone level measured. Categorizing subjects into American Society of Anesthesiologists (ASA) classes revealed a greater proportion of patients aged <60 years were of class II (34%) compared to patients aged 60–70 (16%) and >70 (15%) (p = 0.015). Indigenous patients were more likely to be younger than non-Indigenous patients, 59 compared to 68 (p<0.001), and have a higher preoperative BGL, 9.0 mmol/L (162 mg/dL) compared to 8.2 mmol/L (148 mg/dL) (p = 0.19). Conclusions: POMODA has displayed multiple areas for improvement in the perioperative management of diabetes. The authors recommend that pre-anaesthetic clinics for diabetic patients requiring surgery, particularly Indigenous Australians, be held at least two weeks prior to surgery to allow for optimisation of glycaemic control and clear perioperative instructions, and anticipate this being an important first step in improving guideline compliance.