Perioperative Management in a Patient With Type 1 Diabetes Mellitus Who Presented Severe Hypoglycemia During Dental Implant Surgery

A Case Report

Hajime Shimoda; Tetsu Takahashi

Disclosures

BMC Oral Health. 2018;18(204) 

In This Article

Background

The frequency of opportunities regarding perioperative systemic management for medically compromised patients with diabetes mellitus (DM) is steadily increasing in oral and maxillofacial surgical ambulatory care units. In particular, patients with type 1 DM exhibit poor glycemic control owing to an extreme impairment of glucose tolerance based on insufficient insulin secretion. On the other hand, for patients with diabetes who are undergoing surgery, appropriate glycemic control throughout the perioperative period needs to be maintained to conserve the endocrine-metabolic balance between insulin and hyperglycemia-promoting hormones, such as cortisol and adrenaline. In this report, we discuss perioperative management, including glycemic control, in a dental implant outpatient with type 1 DM.

A case with impending hypoglycemia masked by post-extraction labial paresthesia has been reported in a patient with type 1 DM.[1] However, there are few reports regarding dental implant surgery in patients with type 1 DM. Therefore, the present case is rare or unusual case with respect to an occurrence of acute severe hypoglycemia during dental implant surgery. Thus, this report contributes to the literature in this area. Further, we think that this paper will be of interest to the readership of journal because it raises awareness of the importance of preoperative planning for potential hypoglycemic episodes in patients with type 1 DM.

Case Presentation

A 60-year-old male patient (height: 170 cm, weight: 60 kg) diagnosed with type 1 DM was scheduled for dental implant primary surgery in the right mandibular first and second molar region. The present patient, who had diabetic nephropathy and retinopathy as secondary complications, was prescribed intensification therapy of subcutaneous injection of insulin (ultra-rapid-acting insulin aspart/long-acting insulin glargine). The patient's glycated hemoglobin (HbA1c) level was 6.4%, but he exhibited large and irregular diurnal variations in blood glucose values. Preoperative blood biochemistry examination revealed elevated alkaline phosphatase (492 U/L) and creatine kinase (282 U/L) and decreased albumin (3.6 g/dL) and glucose (39 mg/dL), accompanied by few subjective hypoglycemic symptoms such as nausea, malaise, and drowsiness. Urinary ketone bodies were negative, and an electrocardiogram indicated normal sinus rhythm (84 bpm).

Premedication with peroral antibiotics was carried out to prevent systemic infections that can be derived as a complication of DM. The patient's initial postprandial blood glucose value just before surgery was 90 mg/dL. Preoperative cardiorespiratory parameters showed systolic/diastolic blood pressure of 162/93 mmHg, heart rate of 90 bpm, and oxygen saturation (SpO2) of 98%. Owing to the high blood pressure, the patient was treated to control intraoperative hypertension, with diligent attention to cardiovascular conditions; this was performed under the auspices of the first author, who is a certified dental anesthesiology specialist. An intravenous line with saline fluid was inserted for intravenous administration of nicardipine and/or diltiazem as antihypertensive agents to control blood pressure with noninvasive monitoring, including a lead II electrocardiogram. Local anesthesia with 3% prilocaine containing felypressin (0.03 IU/mL) as a vasoconstrictor for surgical procedures was applied to avoid unstable hemodynamics. Intravenous nicardipine (0.4 mg) and diltiazem (5 mg) were intermittently administered via a bolus injection to achieve a systolic blood pressure level lower than 150 mmHg with good control and stability of hemodynamics.

During surgery, the patient abruptly complained of discomfort such as malaise that seemed to be a symptom of hypoglycemia. At that time, neither conscious nor cardiorespiratory disturbance was confirmed, with blood pressure of 160/75 mmHg, heart rate of 75 bpm, and SpO2 of 96%. Blood glucose was promptly measured at 32 mg/dL and recognized as severe hypoglycemia. Oral glucose and an electrolyte-combined infusion of glucose were administered, and he immediately recovered, with blood glucose increasing to 65 mg/dL 15 min after glucose administration and to 127 mg/dL by the end of the surgical procedure.

The present surgery, involving the placement of a screw-shaped endosseous implant fixture made of titanium in the lower jaw, was smoothly performed precisely as planned. There was no implant placement supplemented by various guided bone regeneration, and no other issues occurred. The surgical procedure resulted in less invasion, limited to the area of implant fixture placement within the right mandibular region of the two molars, compared to commonly performed dental implant surgery that spans the entire lower jaw and is likely to be relatively highly-invasive. The durations of surgery and systemic management were 85 min and 140 min, respectively (Figure 1).

Figure 1.

Intraoperative management record indicating the progress of glycemic control. During dental implant surgery, the patient abruptly complained of discomfort such as malaise that seemed to be a symptom of hypoglycemia. Blood glucose was promptly measured at 32 mg/dL and recognized as severe hypoglycemia. Oral glucose and an electrolyte-combined infusion of glucose were administered, and he immediately recovered, with blood glucose increasing to 65 mg/dL 15 min after glucose administration and to 127 mg/dL by the end of the surgical procedure

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