Sugar

A man with no known history of diabetes comes in for a resection of a brain mass. He hasn't been on any steroids, but on arrival to the pre-operative area, his blood sugar is 450. How do you proceed? Questions like this (I think) are pretty good boards questions because there is not necessarily a black-and-white answer. On boards, you pick a side and justify it as best you can. You don't waffle, but you know that if you have sufficient reasoning, you'll do okay. In real life, though, what do you do?

On the one side, there's a patient who has a brain tumor expecting to have it taken out. Delaying or canceling the case can have serious neurologic consequences. How long will it take for the patient's internist to get his sugars under control? How quickly might this tumor progress? Where is its location and what symptoms has it already caused? Is it really fair to go to a patient who has been planning on this for weeks, who has been fasting for a day and say that you have to cancel for something that is not his fault? What if you cancel this case and the exact same thing happens two weeks later? And there are systems issues too, though they are less important. What happens to your relationship with a surgeon if you cancel too many cases? What's the effect on OR efficiency? Is this really necessary?

On the other hand, 450 is a very high glucose. Someone with undiagnosed severe diabetes has an increased risk for surgery. He may also have undiagnosed coronary, vascular, or kidney disease. How many other things haven't been figured out? Could this be diabetic ketoacidosis? A patient who is going into DKA has a significant risk of dying; he may have hypovolemia, acidemia, and metabolic disturbances. Even if this is just pure hyperglycemia, it leads to increased infections, poor wound healing, and higher mortality. Furthermore, the stress of surgery itself leads to an inflammatory stress response which increases sugars. Even if he is not in DKA right now, surgery can tip that over. How can you justify taking him to surgery?

Of course, real life plays out a lot less dramatically. I consult several of my colleagues and talk to the surgeon about the risks and benefits. Then I spend a lot of time chatting to the patient about my thoughts. Ultimately, we decide that the best course of action is to delay the case several hours to get the glucose under better control. I check labs so that I know I'm not missing any other diagnoses. I administer intravenous insulin until the glucose is better. In the operating room, I place an arterial line and check frequent glucoses to keep the sugars under control. I consult a medicine hospitalist so that he has someone managing his sugars postoperatively. It takes a lot of extra work, but it's the right thing for the patient.