REVIEW

CURRENT
OPINION A not so sweet scenario: impact of perioperative
glucose control on regional anesthetic techniques
for orthopedic surgery
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Maliha Nowrouz and Michael Buxhoeveden

Purpose of review
Diabetes and hyperglycemia are well established risk factors for complications associated with common
orthopedic surgeries. In some practice settings, these conditions are also viewed as contraindications to
regional nerve catheters. In this article, we aim to present our approach to offering the benefits of this
modality in a safe manner for patients with diabetes and even some with preexisting, localized infections.
Recent findings
Evidence suggests that reduction in opioids and avoidance of general anesthesia can be particularly
beneficial for patients with diabetes and high blood sugar, who often suffer from comorbid conditions such
as obesity and obstructive sleep apnea. On our high volume, high acuity acute pain service, we take a
selective approach to nerve catheter placement in this population and even some who already have
localized infections. In our experience, with careful monitoring and risk mitigation strategies these patients
have improved pain control and an exceedingly low rate of complications associated with nerve catheter
use.
Summary
Based on our experience and reading of the literature, we advocate for a liberalized approach to use of
continuous regional anesthesia for diabetic patients having for orthopedic surgery. A set of consensus
guidelines tailored to institutions’ resources and monitoring capabilities can be a useful tool for
standardizing care. It may also increase access to the clinical benefits of this modality in a population
particularly vulnerable to opioid related adverse effects.
Keywords
hyperglycemia, infection, orthopedic surgery, peripheral nerve catheters, regional anesthesia

INTRODUCTION Enhanced Recovery After Surgery (ERAS), many

Joint replacement is one of the most frequently
performed elective surgeries in the United States
[1]. As the population ages, demand is only pro-
jected to increase. It is common for patients who are
candidates for joint replacement to suffer from
orthopedic surgeons are requiring patients to dem-
onstrate improved glycemic control prior to elective
surgery. Centers such as our hospital have introduced
preoperative screening criteria for surgeries ranging
from carpal tunnel release to total joint arthroplasty
&

comorbidities, such as diabetes mellitus [2 ,3].

&
According to the American Diabetes Association,
in 2018 there were over 34 million Americans living
with diabetes and over 1.5 million new diagnoses are
made each year. In 2020, it was estimated that
roughly 22% of total knee arthroplasty patients were
&
diabetic [2 ]. Patients with diabetes have increased
risk of surgical and anesthetic complications includ-
ing higher mortality, delayed wound healing and
&
infection [2 ].
As healthcare moves toward a bundled payment
reimbursement model coupled with the zeitgeist of
(TJA) [2 ]. In TJA, peri-prosthetic joint infections (PJI)
can be catastrophic. The prospect of this feared com-
plication has spurred orthopedic surgery to lead the
Virginia Commonwealth University Health System, Department of Anes-
thesiology, Richmond, Virginia, USA
Correspondence to Maliha Nowrouz, MD, Virginia Commonwealth Uni-
versity Health System, Department of Anesthesiology, 1200 East Broad
Street, West Hospital, 7th Floor, North Wing, Box 980695, Richmond, VA
23298-0695, USA. E-mail: maliha.nowrouz@vcuhealth.org
Curr Opin Anesthesiol 2022, 35:255–258
DOI:10.1097/ACO.0000000000001106

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Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.

 Ethic, economics and outcomes
KEY POINTS
 Diabetes and hyperglycemia increase risk of
complications from orthopedic surgery.
 Glucose control throughout the perioperative period
can improve outcomes even in diabetic patients.
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 Regional and neuraxial anesthetic techniques offer
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important benefits for diabetic patients in the
perioperative period making them ideal for use in
orthopedic surgery.
 Under appropriate circumstances, diabetes,
hyperglycemia and localized infection need not
preclude patients from safely benefiting from
these modalities.
charge in screening for and optimizing this impor-
tant and modifiable risk factor.
Diabetic control has implications for each phase
of the preoperative, intraoperative and postopera-
tive periods. Although there are other measures
essential for reducing infectious complications such
as methicillin-resistant Staphylococcus aureus
screening and decolonization [3], we will focus on
our institution’s approach to glucose management.
For instance, patients with chronic pain syndromes
and preoperative opioid use may well benefit from
placement of a continuous peripheral nerve catheter
for postoperative pain control following total joint
surgery. Given the higher risk of infection in the
setting of diabetes [3], some anesthesiologists may
be reluctant to offer such a modality. More still
might avoid placing nerve catheters in already
infected patients. We aim to present our depart-
ment’s approach to risk assessment and mitigation
regarding the use of regional anesthetic techniques
in this growing population.
PREOPERATIVE OPTIMIZATION
Fortunately, most joint arthroplasties are elective in
nature, providing an opportunity for preoperative
optimization. Apart from a consultation with the
orthopedic team, patients at our institution undergo
rigorous testing and education prior to surgery at an
anesthesia-led preoperative clinic. The goal of our
Preoperative Assessment, Communication and Edu-
cation (PACE) center is to not only discuss what
patients should expect during their perioperative
period, but also provide the opportunity to optimize
a patient to help minimize perioperative morbidity
and mortality. This includes areas such as nutrition,
anemia, smoking, as well as glycemic control. One
of the most well recognized lab parameters of gly-
cemic control is the HbA1c. This blood lab provides
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the percentage of glycosylated hemoglobin found in
serum. It is meant to be a marker of glucose control
over a 3-month period. A large meta-analysis in
2017 found that higher HbA1c percentages were
associated with perioperative hyperglycemia and
perioperative joint infections [4]. The exact cutoff
HbA1c associated with increased infection risk has
been difficult to pinpoint. While some studies dem-
onstrate that greater than 7.7% lead to higher PJI,
other studies have shown no difference in PJI rates
even above 7%. Even though the ideal lab criteria
has yet to be established, the fact remains that
improved glucose control around the time of sur-
gery can mitigate the risk of infection, even in
diabetic patients [4].
Another marker for glycemic control is fructos-
&
amine [2 ]. This value represents the amount of
glycosylated protein found in serum. Unlike HbA1c,
which reflects glucose control over 3 months, fruc-
tosamine has a much shorter half-life of 2–3 weeks.
Some argue this allows for a better idea of a patient’s
glucose in the short term. Studies demonstrate that
higher fructosamine levels were associated with
higher risk of readmission and PJI within 3 months
of initial surgery. A study in 2019 by Shohat et al. [5]
a limit of 293 mmol/l was proposed as a cutoff for
unwanted perioperative risk.
To avoid hypoglycemic crises while maintaining
an appropriate nil per os status prior to surgery, we
ask insulin dependent diabetic patients to reduce
their dose of insulin the night prior to surgery. Short
acting insulin is generally held on the day of surgery
as well as oral hypoglycemic medications. This can
lead to baseline hyperglycemia prior to operating
room and predispose the patient to unwanted peri-
operative infection risk.
At our institution, patients who screen positive
for hyperglycemia or diabetes mellitus may experi-
ence a delay in elective surgery to facilitate preop-
erative optimization. Strategies include referral to
their primary care physician, consultation with
Endocrinology, and diabetes mellitus education.
A more disciplined approach to preoperative
screening and treatment of hyperglycemia has
been associated with a marked decrease in inci-
&
dence of PJI [2 ].
INTRAOPERATIVE CONSIDERATIONS
The first step to good intraoperative glucose control
is for patients to arrive euglycemic on the day of
surgery. Any oral hypoglycemic medications or
insulins taken on the night before or day of surgery
should be determined and documented in the med-
ical record. Blood glucose prior to surgery relative to
their usual range is also helpful in deciding whether
Volume 35  Number 2  April 2022

blood glucose levels should be checked during sur-
gery and how frequently.
The use of point-of-care tests (POCT) and con-
tinuous glucose monitors (CGMs) during surgery are
topics of ongoing debate. Point of care testing blood
glucose monitors are not validated for use on
patients under general anesthesia. Fluid shifts and
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changes in blood flow cause at least theoretical
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concern that there may be a mismatch between
glucose levels in blood drawn at the periphery via
finger-stick compared to blood in central circulation
&
[6 ]. CGMs may also be less accurate during surgery,
possibly as a result of interference from electrocau-
&
tery devices [7 ]. The use of CMG in the operating
room and its comparison to point of care glucose
monitors is the focus of at least one ongoing clinical
trial at this time. Use of regional nerve blocks as
primary anesthetics and avoidance of the physio-
logic changes associated with general anesthesia
facilitates the safe use of POCT for blood glucose
monitoring during surgery.
Patients with high blood sugar often present with
metabolic syndrome and comorbid obesity, hyper-
tension and/or obstructive sleep apnea [8]. This com-
mon scenario can present seemingly competing
clinical objectives when it comes to pain manage-
ment during orthopedic surgery. Anesthesiologists
may find themselves balancing the desire to mini-
mize opioid use and its associated complications in
this vulnerable group with the risk of infection that
could arise from use of peripheral nerve catheters.
Regional anesthetic techniques have become an
indispensable tool in modern anesthetic care. They
are known to reduce total opioid consumption while
in hospital, decrease time to hospital discharge,
reduce postoperative nausea and vomiting as well
as complications associated with over-sedation and
&&
respiratory depression [9 ]. Although each case war-
rants consideration on its own merits, a consensus
approach for pain management among surgeons and
anesthesiologists is helpful. Anesthetic plans should
take into account the risks, benefits and mitigation
strategies associated with general anesthesia and sys-
temic pain medications as well as those associated
&&
with neuraxial or regional anesthesia [9 ].
Surgical trauma and pain response are known to
lead to release of stress hormones such as cortisol,
epinephrine, and glucagon which increase glucose
&&
levels and insulin resistance [3,9 ]. A prospective,
randomized clinical trial comparing spinal and gen-
eral anesthesia for elective hip replacement surgery
showed that spinal anesthesia was associated with
less hyperglycemia in both diabetic and nondiabetic
patients [10]. This further underlines the importance
of neuraxial and regional anesthesia for these
orthopedic procedures.
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A not so sweet scenario Nowrouz and Buxhoeveden
POST-OPERATIVE CONSIDERATIONS
Inpatient status may be a mitigating factor when
assessing the risk of continuous nerve blockade tech-
niques in patients at high risk of infection due to
poorly controlled blood sugar. An acute pain rounding
service or even the primary team can monitor the
insertion site as well as other clinical and laboratory
findings indicative of infection. This may be especially
beneficial in patients who are not able to reliably self-
monitor or seek care quickly if infection develops.
At our institution, the use of peripheral nerve
catheters is not limited to inpatients. Appropriate
outpatients are provided continuous analgesia via
perineural catheters for typically 72 h postopera-
tively. Candidates typically have a good support
system and reliable form of contact. They also
require the ability to monitor for signs of infection
such as fevers, erythema, swelling or drainage from
the catheter site. All catheter patients receive exten-
sive education prior to discharge with close follow
up via daily phone call by anesthesia trained staff.
SPECIAL PATIENT POPULATION: PRE-
EXISTING INFECTIONS
Infection of joints, wounds or surgical hardware is a
problematic complication of orthopedic surgery. Dia-
betes and poor glucose control are often factors con-
tributing to this complication [3]. Some
anesthesiologists may be hesitant to offer continuous
regional nerve catheters in this group due to the
concern for worsening infection or catheter-associ-
ated infection. However, we suggest that even in
infected patients, peripheral nerve catheters may be
safely employed for use as either a primary anesthetic
or for postoperative pain control. Based on our clinical
experience, factors which may be reassuring in these
cases include localized infection, careful aseptic tech-
nique, down-trending leukocytosis, prior initiation of
antibiotics and negative cultures. Infectious risk may
be mitigated by keeping the catheter insertion site
away from the area of infection and limiting duration
of use. Improved pain control can facilitate better
&&
wound care both in the hospital and at home [11 ].
This may actually lead to better healing and reduced
infection, though no published studies on the subject
were found. Inpatient status may reduce risk for
patients with poor health literacy, unreliable follow
up or communication barriers. This is because the
clinical exam and lab work can be followed daily while
the catheter is in place. If signs of infection were to
develop the catheter could be promptly removed.
Alternative methods should be used for patients with
systemic infection or infection involving the catheter
insertion site. While the complications associated
with orthopedic surgery in the setting of poor
www.co-anesthesiology.com 257
 Ethic, economics and outcomes
perioperative glycemic control are well established,
many surgeons and healthcare systems are taking prac-
tical new steps to address this modifiable risk factor.
Rigorous new standards and approaches have been
developed to screen and optimize patients during each
phase of the perioperative timeline. The driving force
behind this effort may include surgeons, departments,
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healthcare systems or insurance companies.
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CONCLUSION
In summary, the objective of glycemic management
optimization is to reduce complications such as
surgical site infection, readmission, reoperation
and delayed wound healing. Peripheral nerve blocks
have many benefits which may be especially advan-
tageous to patients with diabetes and infections who
are undergoing orthopedic surgery. Nerve catheters
may obviate the need for general anesthesia and
decrease or eliminate the need for opioids during
surgery or wound care. Regional and neuraxial tech-
niques can also reduce stress hyperglycemia, poten-
tially further aiding with reduction in surgical site
infection. Based on our experience, we contend that
with appropriate precautions, nerve blocks and
peripheral nerve catheters can be safely offered to
patients with diabetes, high blood sugar and even
some patients being treated for localized infections.
Acknowledgements
We would like to thank Drs Alice Coombs, Astrid Over-
holt and Katherine Xie for reviewing this article.
Financial support and sponsorship
None.
Conflicts of interest
There are no conflicts of interest.
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REFERENCES AND RECOMMENDED
READING
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been highlighted as:
& of special interest
&& of outstanding interest
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