Surgery pre-op checklist for people with diabetes   (June 29, 2008)

[Editor's Note: A follow-up discussion of this topic was written in January 2012: A Checklist for Patients with Diabetes When Surgery is Planned.]

A checklist can help eliminate mistakes. Seems like common sense, and everyone's aware that airplane pilots have been using pre-flight checklists for years. In hindsight, it's amazing, but surgeons have not been using pre-op checklists routinely.

But WHO (the World Health Organization) recently announced that using a checklist helps make surgery safer (New checklist to help make surgery safer). They report that "preliminary results from a thousand patients in eight pilot sites worldwide indicate that the checklist has nearly doubled the likelihood that patients will receive proven standards of surgical care. Use of the checklist in pilot sites has increased the rate of adherence to these standards from 36% to 68% and in some hospitals to almost 100%. This has resulted in substantial reductions in complications and deaths in the 1000 patients. Final results on the impact of the checklist are expected in the next few months."

The "Safer Surgery Checklist" involves checks that are extremely basic, ranging from confirming the site for surgery (which limb to amputate or kidney to remove) to counting the number of swabs after the operation has been completed (to ensure none have been left inside the patient).

Worldwide, the WHO aims to have the checklist operating in 2,500 hospitals in the most populous countries (with 75 per cent of the world's population) by the end of next year. According to Dr Atul Gawande, a surgeon who's leading the intiative for WHO, "We want it to be in every operating room in the world. We know it works and it has virtually no cost."

The present draft of the checklist is available on-line at WHO Guidelines for Safe Surgery. This document does indicate only one concern for people with diagnosed or undiagnosed diabetes, stating "it is likely that all surgical patients could benefit from perioperative screening of glucose level and continuous insulin infusion in the perioperative period when glucose levels are elevated." But that's all it says about diabetes. What about other diabetes concerns before and during surgery?

Let me add some examples:

1) Pre-op evaluation of the patient with diabetes must include clarification of who's going to manage the blood glucose level. Will it be the surgeon? The patient's family doc? An endocrinologist? A hospitalist? The anesthesiologist? It's not my concern here about the specialty of the physician running the diabetes show, only that someone must be identified in advance, and that person must have the knowledge to write orders for controlling the diabetes, and must be available to advise on adjusting the orders if things get out of hand for whatever reason.

2) Metformin, a commonly-used medication for T2DM, should be stopped pre-operatively, as having metformin on board during surgery increases the risk of a potentially-fatal complication called lactic acidosis. Hence any diabetes pre-op checklist should include the question: "Has the patient been on metformin? If so, has it been discontinued?"

3) Patients frequently have their oral intake stopped at midnight before surgery, even if the surgery is scheduled for mid-afternoon. This risks dehydration, and indeed if diabetes pills or insulin therapy is withheld due to outdated pre-op protocols, compounds the risks of dehydration with a risk of hyperglycemia. So, pre-op checklists for diabetes should include modification of the "NPO at midnight" instruction if surgery will be in the afternoon hours.

4) And how about a hideously simple question: who will monitor BG levels in the OR?

I think it's entirely inappropriate for a blood specimen to be sent to the hospital laboratory for a "STAT BG" when meters are everywhere -- BG meters should definitely be in the OR, and someone should be trained in their use; and the appropriate control solutions run to verify that the meter is correctly calibrated.

I think these and many other thoughts should be added to a proposed surgery pre-op checklist for people with diabetes. And I think some organization should take charge of developing this checklist, perhaps AACE, or AADE, or ADA. I don't care who develops it. But I sure hope they work one out and have it available for all surgeons to use by the time the WHO checklist is widely used, at the end of next year.

Until then, you and your diabetes doc should think through what factors about your diabetes would be crucial for you to survive surgery, and together, make sure that you have your own personal pre-op checklist.