Perioperative management of adult diabetic patients. Specific situations

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Perioperative management of adult diabetic patients.

Specific situations

Gaelle Cheisson, Sophie Jacqueminet, Emmanuel Cosson, Carole Ichai,

Anne-Marie Leguerrier, Bogdan Nicolescu-Catargi, Alexandre Ouattara, Igor

Tauveron, Paul Valensi, Dan Benhamou

To cite this version:

Gaelle Cheisson, Sophie Jacqueminet, Emmanuel Cosson, Carole Ichai, Anne-Marie Leguerrier, et al..

Perioperative management of adult diabetic patients. Specific situations. Anaesthesia Critical Care &

Pain Medicine, Elsevier Masson, 2018, 37 (Supplement 1), pp.S31-S35. �10.1016/j.accpm.2018.02.022�.

�hal-02621646�

(2)

Guidelines

Perioperative

management

of

adult

diabetic

patients.

Speciﬁc

situations

Gae¨lle

Cheisson

a

,

Sophie

Jacqueminet

b

,

Emmanuel

Cosson

c,d

,

Carole

Ichai

e,f

,

Anne-Marie

Leguerrier

g

,

Bogdan

Nicolescu-Catargi

h

,

Alexandre

Ouattara

i,j

,

Igor

Tauveron

k,l,m,n

,

Paul

Valensi

c

,

Dan

Benhamou

a,

*

,

working

party

approved

by

the

French

Society

of

Anaesthesia

and

Intensive

Care

Medicine

(SFAR),

the

French

Society

for

the

study

of

Diabetes

(SFD)

a

Departmentofsurgicalanaesthesiaandintensivecare,SouthParisuniversityhospital,hoˆpitaldeBiceˆtre,AP–HP,78,rueduGe´ne´ral-Leclerc,94275LeKremlin-Biceˆtre, France

b

Instituteofcardiometabolismandnutrition,Departmentofdiabetesadmetabolicdiseases,hoˆpitaldelaPitie´-Salpeˆtrie`re,AP–HP,75013Paris,France

c

Departmentofendocrinology,diabetologyandnutrition,hoˆpitalJean-Verdier,AP–HP,Paris13university,SorbonneParisCite´,CRNH-IdF,CINFO,93140Bondy,France

d_UMR_U1153_Inserm,_U1125_Inra,_CNAM,_Sorbonne_Paris_Cite´,_Paris₁₃_university,₉₃₀₀₀_Bobigny,_France

e_Department_of_versatile_intensive_care,_hoˆpital_Pasteur_2,_CHU_de_Nice,_30,_voie_Romaine,₀₆₀₀₁_Nice_cedex_1,_France f

InsermU1081,CNRSUMR7284(IRCAN),UniversityHospitalofNice,06001Nice,France

g

Departmentofdiabetologyandendocrinology,CHUdeRennes,hoˆpitalSuduniversityhospital,16,boulevarddeBulgarie,35056Rennes,France

h

Departmentofendocrinologyadmetabolicdiseases,hoˆpitalSaint-Andre´,Bordeauxuniversityhospital,1,rueJean-Burguet,33000Bordeaux,France

i

Bordeauxuniversityhospital,DepartmentofAnaesthesiaandCriticalCareII,MagellanMedico-SurgicalCentre,33000Bordeaux,France

j

Inserm,UMR1034,BiologyofCardiovascularDiseases,universite´ deBordeaux,33600Pessac,France

k_Department_of_{endocrinology}_and_diabetology,_{Clermont-Ferrand}_university_hospital,_58,_rue_{Montalembert,}₆₃₀₀₀_{Clermont-Ferrand,}_France l_UFR_me´decine,_{Clermont-Auvergne}_university,_28,_place_{Henri-Dunant,}₆₃₀₀₀_{Clermont-Ferrand,}_France

m

UMRCNRS6293,InsermU1103,GeneticReproductionanddevelopment,Clermont-Auvergneuniversity,63170Aubie`re,France

n

Endocrinology-Diabetology,CHUG.-Montpied,BP69,63003Clermont-Ferrand,France

ARTICLE INFO Articlehistory:

Availableonline16March2018 Keywords: Diabetes Perioperative Ambulatorysurgery Pregnancy Gestationaldiabetes Basal-bolus ABSTRACT

Ambulatorysurgerycanbecarriedoutindiabeticpatients.Byusingastrictorganisationalandtechnical approach,theriskofglycaemicimbalanceisminimised,allowingthepatientstoreturntotheirprevious wayoflifemorequickly.Takingintoaccountthecontextofambulatorysurgery,withasameday discharge,theaimsaretominimisethechangestoantidiabetictreatment,tomaintainadequateblood sugarcontrolandtoresumeoralfeedingasquicklyaspossible.Thepreoperativeevaluationisthesame as for a hospitalised patient and recent glycaemic control (HbA1c) is necessary. Perioperative managementandtheadministrationoftreatmentdependonthenumberofmealsmissed.Thepatient canreturnhome aftertakingupusualfeedingand treatmentagain.Hospitalisationisnecessary if signiﬁcantglycaemicimbalanceoccurs.Inpregnancy,itisnecessarytodistinguishbetweenknown pre-existingdiabetes(T1DorT2D)andgestationaldiabetes,deﬁnedasglucoseintolerancediscoveredduring pregnancy.Duringlabour,blood sugarlevelsshouldbe maintainedbetween0.8and 1.4g/L(4.4– 8.25mmol/L).Controlofbloodsugarlevelsisobtainedbyusingacontinuousadministrationofinsulin usinganelectronicsyringe(IVES)togetherwithaglucoseinfusion.Post-partum,managementdepends onthetypeofdiabetes:inT1DandT2Dpatientsabasal-bolusschemeisrestartedwithdecreaseddoses whileingestationaldiabetesinsulintherapyisstoppedafterdelivery.Antidiabetictreatmentisagain necessaryifbloodsugarlevelsremain>1.26g/L(7mmol/L).

C ₂₀₁₈_The_Authors._Published_by_Elsevier_Masson_SAS_on_behalf_of_{Socie´te´ franc¸aise}_{d’anesthe´sie}_et_de

re´animation(Sfar).ThisisanopenaccessarticleundertheCCBYlicense(http://creativecommons.org/ licenses/by/4.0/).

* Correspondingauthor.

E-mailaddress:dan.benhamou@aphp.fr(D.Benhamou).

https://doi.org/10.1016/j.accpm.2018.02.022

2352-5568/ C₂₀₁₈_The_Authors._Published_by_Elsevier_Masson_SAS_on_behalf_of_{Socie´te´ franc¸aise}_{d’anesthe´sie}_et_de_{re´animation}_(Sfar)._This_is_an_open_access_article_under_the

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1. Ambulatorysurgery

ThemainelementsaresummarisedinPracticalsheetL.

Ambulatory surgery (AS) is a form of management that is

becomingmorecommon;in2014,approximately45%ofsurgical

proceduresinFrancewerecarriedoutinambulatoryconditions

[1].Althoughthisﬁgureisbelowthatobservedinseveralother

industrialised countries, comparisons are difﬁcult because, the

deﬁnitionof the duration of hospital varies between countries

(12h in France and<24h without spending the night in

hospitalinseveralothercountries).Alsotermssuchasdaysurgery,

same-daysurgery,day-case surgery,day-caresurgery refertoa

durationofstay24hwhilethetermoutpatientsurgeryshould

beusedforaprocedureperformedunderlocalanaesthesiawithout

theneedforspeciﬁcpostoperativeobservation[2].

TheselectionofpatientsforAStraditionallytakesintoaccount

twomainfactors:

thenatureoftheprocedurewith, essentially,theselectionof

interventionsinvolvingminorsurgery,suchasthoseidentiﬁed

bymarkeracts[3];

theunderlyingterrainandco-morbidities,withfrailpatientsor

thosewithahigh-riskdisease, notablycardiacorrespiratory,

usuallybeingexcludedfromAS.

Today,therecommendationsofSFAR[4]donotputanybarriers

inplaceregardingthesetwocriteria,considerablyincreasingthe

numberofeligiblepatients.

Historically,diabeticpatientshavebeendeclinedASforseveral

reasons,includingalterationsofmajororgans,whichincreasethe

perioperativerisk.Thepresenceofdiabetestreatedwithinsulinis

associatedwith anincrease in the perioperative riskby 1point

accordingtotheRCRIorLee’sscore[5]witheachchangeof1point

having a quasi-exponential effect on the risk of cardiovascular

morbidity during surgery. It was therefore considered that

traditional hospitalisation was better tailored to these patients,

allowingcloserhospital observationand monitoring.Itwas also

thoughtthattheglycaemicimbalanceindiabetics,occurringduring

theperioperativeperiodwouldbebettercontrolledbytraditional

hospitalisation.Today,theoppositeviewistakenanditissuggested

that AS, by a closer organisational and technical approach,

minimisestheriskofglycaemicimbalanceandallowspatientsto

returntotheirpreviouslivingconditionsquicker.Manydiabetic

patients(notablythosewithT1D)knowhowtoeffectivelymanage

andcontroltheirownbloodsugarlevelsathomepostoperatively

andmaintain(ortorebalance)theirglucosebloodconcentration.

Furthermore,visceraldamagesecondarytothediseaseisoften

associatedwithmajorsurgery(cardiacsurgeryforexample),yet

vasculardamageisalsoresponsibleforchangestootherorgans,

suchastheeye,wheresurgerysuitstheambulatorypatient.

Therearerelativelyfewrecentstudiesassessingthemanagement

ofdiabeticpatientsinAS;we onlyfoundasinglerecommendation[6]

andtwostudiesassessingpracticesandpublishedoverthepastﬁve

years[7,8]. Overall,the logicalobjectives inthis situationareto

maintainadequateglycaemiccontrolandtoavoidhypoglycaemia.

Takingintoaccountthecontextofthissurgery,withreturnhomethe

sameday, it is logical to minimise the changes toantidiabetic

treatment,to resumeoral feedingas quickly aspossible and to

regularlymonitorbloodsugarlevels.ForDiNardoetal.[7],the

anaesthetististhemostcompetentpersonto guidemanagementand

tomakethenecessarychangestotreatment.

1.1. Preoperativeevaluation

The evaluationisthesameasfora hospitalisedpatient.The

criteriathat mayleadtosurgery beingdeclinedortemporarily

postponed dependon thesurgical indication,on poorglycaemic

controland/oronpoortoleranceofdiabetes.Forexample,recurrent

thoracicpainornewEKGsignsinthecontextofnon-urgentsurgery

mayleadtothesurgicalprocedurebeingpostponedandadditional

assessment of the patient being encouraged. Knowledge of the

result of a recent HbA1c measurement will help to deﬁne the

strategy.Avaluebetween6and8%isreassuringaboutthequalityof

long-termtreatmentandthepatient’scompliancewithtreatment.

Close observation and glycaemic control will help to avoid

imbalanceandthe needforsuddenhospitalisation.Avalue<6%

or>8%mayleadtoapostponementof surgeryorat leasttoa

requestfortheadviceofthereferringphysician.

If thediabetic hasnot had their HbA1c checkedfor several

months,areviewofprescribedmedicationmaybenecessary,as

thereisacorrelationbetweenthevalueforthisparameterandthe

risk of complications in traditional surgery [9]. During the

preoperative anaesthesia consultation, information about the

current treatment is obtained. The patient is told that in the

contextofAS,treatmentshouldnotbemodiﬁed(exceptifalonger

durationofhospitalisationthannormalisneededorifthepatient

doesnotimmediatelyresumefeeding).Nospeciﬁcpremedication

isrequired.

1.2. Perioperativestrategy

The evening before AS, the patient takes his/her usual

treatmentsandeatsnormally.UponadmissiontotheASunit,a

peripheralvenouslineisinsertedbuta glucoseinfusionis only

necessaryifresumptionoforalfeedingisdelayed(seebelow).Care

may be regulated according to the number of meals that the

patientisgoingtoskip.

In the majority of cases, a single meal (on the morning of

admission)ismissed.Thepatientmayhoweverdrinkclearﬂuids

beforehospitaladmission.

Ifsurgeryisshortandthepatientistransferredtothedischarge

room[afterleavingthePostAnaesthesiaCareUnit(PACU)]before

10am,breakfastisservedtothepatientwhotakeshis/hermorning

medicationatthattime.Inthissituation,itisacceptedthatthere

will be a small delay, but the usual routine of the patient is

respected.Priorityshouldthusbegiventodiabeticpatientsonthe

surgicallist.

IfleavingthePACUoccurslater,between10amandnoon,the

patientshouldnottakehis/herusualmedicationinthemorning

beforegoingtothehospitalbuttakeitonarrivalathospitalanda

glucoseinfusionissetup(G10%40mL/h)onarrivalintheASunit.

Infusion should be continueduntil thenext meal if treatment

includes insulin or an insulin secretor drug (sulphonamide or

glinide).

IfthepatientisscheduledtoleavethePACUevenlater(after

12:00), a light breakfast (including solids) is provided and

medicationisingestedbeforegoingtothehospital.Aperipheral

venouslineisinserted,butaglucosesolutionisnotnecessary.

Ifsurgery andanaesthesia arescheduledsothat thepatient

doesnotmissameal,treatmentiscontinuedandthepatienthas

theirbreakfastasusual.

1.3. Glycaemiccontrol

CapillarybloodsugarlevelsaremeasuredonarrivalintheAS

unit.Aglycaemicobjectivebetween5and10mmol/L(0.9–1.8g/L)

is recommended. An insulin (ultra-rapid analogue) bolus is

administered if the capillary blood sugar level is>10mmol/L

(1.8g/L).Duringtheprocedure,thebloodsugarlevelismeasured

hourly,especiallyifsurgeryislengthy.

If the blood sugar level is>16.5mmol/L (3g/L), surgery is

postponedandtreatmentwithacorrectivebolusisadministered

G.Cheissonetal./AnaesthCritCarePainMed37(2018)S31–S35 S32

(4)

with measurement of blood sugar levels every 2h. If such

treatmentleadstoa rapidcontrolofthebloodsugarlevelthen

surgerycanbecarriedout.Ifglycaemicimbalancepersistswith

blood sugar levels>16.5mmol/L (3g/L), thepatient should be

admittedtohospitalandIVESinitiated.

1.4. Postoperativeperiod

Oral feeding is resumed as soon as possible and repeated

measurementofbloodsugarlevelscontinued.

If blood sugar levels are 10mmol/L (1.8g/L), the regular

treatmentsareresumedattheusualtimes.

Ifbloodsugarlevelsbecome>10mmol/L(1.8g/L),thepatient

should remain in hospital and receive intermittent injections

ofcorrectivesubcutaneousbolusesuntilglucoselevelsdecreaseto

5–10mmol/L(0.9and1.8g/L).

Ifbloodsugarlevelsbecome>16.5mmol/L(3g/L),discharge

homeiscontraindicatedandthepatientisdmittedtohospitalin

ordertoinitiateIVESinsulintherapy.

Overall,ambulatorysurgeryispossibleinadiabeticpatientand

general rules of ambulatoryanaesthesia arefollowed.

Manage-ment of thediabetic patient depends on thenumber of meals

missed.ThesestrategiesaresummarisedinpracticalsheetL.

2. Pregnancyanddiabetes(practicalsheetN)

2.1. Deﬁnitionandphysiology

Duringpregnancy,itisnecessarytodistinguishbetweenknown

pre-existingdiabetesandgestationaldiabetes.

2.1.1. Pre-gestationaldiabetes

T2DisnowmorecommonthanT1Dinpregnantwomen.These

twotypesofdiabetesaretreatedwithinsulinduringpregnancy,

possiblywithaSCinsulinpump(60%ofT1D,10%ofT2D).Froma

physiologicalstandpoint,bloodsugarlevelsdecreaseintheﬁrst

trimesterandwomenmaybesubjecttohypoglycaemia.Insulin

resistancethenoccurs,thedosesofinsulinareincreasedupto

3-fold[10].InwomenwithT1D,thereisariskofketosis,oreven

ketoacidosis,evenwhenbloodsugarlevelsareonlymoderately

elevated[11].Screeningforketosisshouldthereforebecarriedout

ifthereareclinicalsignsevenwithbloodsugarlevels<11mmol/L

(2g/L),duetotheriskoffoetaldeathintheabsenceoftreatment.

2.1.2. Gestationaldiabetes[12]

Gestationaldiabetesisdeﬁnedasglucoseintolerance

discov-eredfortheﬁrsttimeduringpregnancyandwhichcorrespondsto

twoscenarios,either:

hyperglycaemiagenerallyoccurringatorafterthe24thweek

against a background of physiological insulin resistance

(approximately85%ofcases);

pre-diabetesorT2Dexistingbeforethepregnancybutignored.

When blood sugar levels are very high during screening,

we refer to ‘‘true diabetes discovered during pregnancy’’

(Appendix 1). Despite screeningin thepresenceof risk factors,

the prevalence of gestational diabetes increases regularly. For

example, in France, it occurs in 8.3% of pregnancies, or

approximately50,000 pregnanciesper year. Treatmentinitially

isbasedondietarymeasuresassociatedwithauto-observationof

bloodsugarlevels4–6timesadayandinsulintherapy(20–30%of

cases).Theobjectivesaresimilarforalltypesofdiabetes;fasting

blood glucose<5.2mmol/L (0.95g/L) and 2h after a

meal<6.6mmol/L(1.20g/L).

2.2. Risksassociatedwithdiabetesduringdelivery

TherisksofcomplicationsarehigherforwomenwithT1D,then

T2D, than for those with gestational diabetes. Compared to

patients without diabetes, the risks associated with caesarean

deliveryareincreased4.3-,3.2-and1.4-fold,respectively,andfor

eclampsia6.6-,4.0-and1.6-fold.Theneonatalprognosisfollowsan

identicalcurveformacrosomia(vs.nodiabetes,OR=7.7,3.8and

1.8, respectively); with a risk of respiratory distress (OR=2.1,

1.7 and 1.3, respectively). Perinatal mortality is increased in

womenwithpre-gestationaldiabetes(OR=3.6forT1Dand1.8for

T2D),withanincreasedriskofperinatalmortality(OR=1.3)when

labouroccursafter37weeks[13].Thereisalsoariskofneonatal

hypoglycaemia,whichisgreaterinwomenwithpoorglycaemic

controlduringpregnancyand duringlabour,revealedbyraised

HbA1c[14–17].Maternalhyperglycaemiainducesfoetal

hyperin-sulinism, which decreases 24 to 48hours post-partum, while

maternal carbohydrate supplies are stopped immediately after

birth.Theprevalenceofneonatalhypoglycaemiais10–40%andis

evenhigherwhen infantsarebornfromamotherwithT1D,or

whentheneonateshavemacrosomiaorincaseofprematurity.The

consequences, mainly of neurological origin, arerelated tothe

durationandseverityoftheseneonatalhypoglycaemicepisodes.

2.3. Glycaemicobjectivesduringlabouranddelivery

The glycaemic objectives during labour are determined

in relation to the risk of neonatal hypoglycaemia. Objectives

(3.8–6mmol/L[0.7–1.10g/L])havebeendescribedintherecent

Guidelines from the American College of Obstetricians and

Gynaecologists and the National Institute for Health and Care

Excellence[11].Similarly,theSFDrecommendsobtainingblood

sugarlevelsthatareclosetonormal[18].

Earlier studies have shown variable results regarding the

absence of neonatal hypoglycaemia when a strict glycaemic

controlisachievedinthemotherduringlabour[19,20].Neonatal

hypoglycaemiacanindeedoccurevenwhenmaternalbloodsugar

levels are controlled during labour. In a retrospective study of

197womenwithT1D,46%ofneonateshadhypoglycaemiaand

there wasnocorrelationbetween neonatalandmaternal blood

sugar levels when the latter were maintained between 4 and

8mmol/L (0.72–1.44g/L). Conversely, there was a signiﬁcant

negativecorrelationbetweenneonatalandmaternalbloodsugar

levelswhenthelatterwere>8mmol/L(1.44g/L)[16].Byusinga

continuous glucose monitoring system in order to adapt

insulin therapy to maintain blood sugar levels between

0.8 and 1.5g/L (4.4 and 8.25mmol/L), one group reported the

absence of hypoglycaemia [21]. We thus propose the same

glycaemic objectives as those proposed by Lepercq et al.,

i.e. maternal blood sugar levels between 0.80 and 1.40g/L

(4.4–8.25mmol/L)[15].

2.4. Actionstobetaken

Practical sheetNdescribes actionstobetakenfor thethree

typesofdiabetesduringthethreedifferentphasesofchildbirth.

2.4.1. Duringdilationofthecervix

Thetreatmentforeachtypeofdiabetesiscontinuedasduring

pregnancywiththesameglycaemicobjectives.

2.4.2. Duringdelivery

2.4.2.1. Insulin therapy. In patients with T1Dor T2D, and those

withgestationaldiabeteswithbloodsugar levels>8.25mmol/L

(1.40g/L) IVES insulin will take over insulin injections during

(5)

the PACU. In women treated using a SC insulin pump, it is

preferabletochangetoIVEStreatment.Retentionoftheinsulin

pump during labour is possible but requires a personalised

protocolforadaptationoftheinsulinpumpoutputduringlabour.

Thereisahighriskofketosisifinsulintherapyisinterruptedina

patientwithT1D.Inthecaseofgestationaldiabetes,IVESinsulin

will only be used if the glycaemic objective is not obtained

(glycaemia>1.40g/Lor8.25mmol/L).

2.4.2.2. Glucoseinfusion. Labourisastaterequiringthe

consump-tion of energy during the active phase, expulsion and when

durationisprolonged.Patientstreatedwithinsulinrequireglucose

(10%)infusiontoavoidmaternalhypoglycaemiaandketosisdueto

fasting.

2.4.3. Immediatepost-partum

Afterbirth,thecourseofactiondependsonthetypeofdiabetes.

Anticipation is necessary and the protocol planned using a

documentwrittenbyadiabetologist(Appendices2and3).

Theglycaemicobjectivesarenotasstrictafterlabour,witha

proposedrangebetween 6and8.8mmol/L(1.10–1.60g/L)after

vaginaldelivery andslightlyloweraftera caesarean section,to

supportwoundhealing[11].

Iftheprotocolisnotdeﬁned,theprinciplesforthemanagement

ofdiabetesareasfollows:

inT1D:resumethebasal-bolusinsulinscheme,withadecrease

indoseofinsulin(either80%ofthedosesusedbeforepregnancy

or50%ofthedosesattheendofpregnancy).Dosesofinsulinwill

indeed have to be doubled or tripled during the pregnancy

[10]. Itshouldbe rememberedthatT1D patients are usually

autonomousinthemanagementoftheirdiabetesandthatbasal

slow insulin should never be stopped. When the electronic

syringeisstopped,slowinsulinshouldimmediatelyberesumed

ifthelastinjectionhasbeenadministered>24hago(ifslow

insulin isinjectedoncea day).If thepatientis on aninsulin

pump,itshouldberestartedassoonastheelectronicsyringeis

stopped;

ininsulin-treatedT2D:insuliniscontinuedathalf-dosewhile

awaitingtheadviceofadiabetologist;

ingestationaldiabetes:insulinisstopped.Monitoringofblood

sugarlevelsbeforeand2hafteramealiscontinuedfor48h.

Treatmentshouldbediscussedwitha diabetologistiffasting

bloodsugarlevelsare>1.26g/L(7mmol/L)andpost-prandial

bloodsugarlevelsare>2g/L(11mmol/L).

Disclosureofinterest

Theauthorsdeclarethattheyhavenocompetinginterest.

Themembersoftheworkingpartyhavereceivedsupportfrom

theFrenchSociety of Anaesthesia and IntensiveCare Medicine

(SFAR)andtheFrenchSocietyfortheStudyofDiabetes(SFD)for

transportandaccommodationwhennecessary.Thetwonational

bodieshavealsoprovidedhonorariafortranslationofthetexts.

Appendix1. Screeningforgestationaldiabetes

Early screening for dysglycaemia is recommended in

womenatriskbymeasuringthefastingbloodsugarlevel(FBS).

Ifearlyscreeningisnormal,screeningiscarriedoutafter24weeks

(wheninsulinresistance increases)afteranoral glucoseloadof

75g.

Riskfactors

Bodymassindex(BMI)25kg/m2

Age35years

Personalhistoryofgestationaldiabetes

1st_degree_family_history_of_T2D

Historyofmacrosomia(bigbaby)

Firsttrimester:fastingbloodsugar(FBS)

Indication:womenwithatleast1riskfactor

FBS<0.92g/L(5mmol/L):normal;screeningbetween24and

28weeksafteroralloadingwith75gglucose

Between 0.92 and 1.25g/L (5–6.9mmol/L): start gestational

diabetesmanagement

FBS1.26g/L(6.9mmol/L):truediabetesdiscoveredduring

pregnancy

Secondtrimester:hyperglycaemiaprovokedbyoralloadingwith

75gglucose

Indication:

Woman witha risk of FBS<0.92g/L (5mmol/L) in the ﬁrst

trimester

Womenwithoutanyriskfactorbutpresentingwithmacrosomia

onultrasoundassessment

Interpretationofresult:

Gestationaldiabetes:

IfFBSisbetween0.92g/Land1.25g/L(5–6.9mmol/L)

and/orbloodsugarlevels1h(G1h)afterloading1.80g/L

(10mmol/L)

and/or blood sugar levels2h(G2h) after loadingbetween

1.53and1.99g/L(8.4–11mmol/L)

Recogniseddecompensateddiabetesduringpregnancy:

FBS1.26g/L(6.9mmol/L)

and/orG2h2g/L(11mmol/L)

Appendix2. Modelofcommunicationformforpost-partum

management

Communicationdocumentforpost-partummanagement

DIABETOLOGIST-PATIENT-MATERNITY

Name,Firstnameofpatient:

Typeofdiabetes:

(DT1,DT2,gestational,other)

Treatmentattheendofpregnancy:

(Dietaryonly/insulinscheme,dose)

G.Cheissonetal./AnaesthCritCarePainMed37(2018)S31–S35 S34

(6)

Immediatepost-partum

-Insulintherapy Tobe

continued

Stopand

observe

Schemeanddoseofinsulintoresumeafterstoppingtheinsulin

electronicsyringe(DT1andDT2):

InD1Tdiabetes,basalinsulinshouldneverbestopped,riskof

ketoacidosis++

*Insulinslow(long-acting):

*Ultra-rapidanalogue:

*Pump(basalandbolus):

-Oralantidiabeticdrugs: YES NO

Type 2 diabetes, without

breast-feeding

Type,dose

- Observation of capillary

bloodsugarlevels

(Frequency,objectives)

Waking 0.80to1.60g/L Post-prandial <1.80g/L

Pre-prandial 0.80to1.60g/L Sleeping <1.80g/L

-Diabetological evaluation

recom-mendedbeforedischarge

YES NO

-Post-partumconsultation

Consultationwithadiabetologistin2-3months:

Consultationwiththetreatingphysicianin2-3months

Other:

-Assessmentstoprescribeatthisconsultation

HbA1c

Fastingbloodsugar

Bloodsugarlevels2hafteroralloadingwith75gglucose

Appendix3. Practicalsheetforintrapartumobservation

Diabetes–Hourlymonitoring

Name:... Date:.../.../... Time (hr) D10%W (mL/h) Ultrarapid insulin (IU/h) Capillary blood glucose(g/L ormmol/L) Ketonaemia or ketonuria Comments References

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