Perioperative Considerations for Evolving Artificial Pancreas Devices

Anesth Analg. 2019 May;128(5):902-906. doi: 10.1213/ANE.0000000000003779.

Abstract

Type 1 diabetes mellitus is a lifelong condition. It requires intensive patient involvement including frequent glucose measurements and subcutaneous insulin dosing to provide optimal glycemic control to decrease short- and long-term complications of diabetes mellitus without causing hypoglycemia. Variations in insulin pharmacokinetics and responsiveness over time in addition to illness, stress, and a myriad of other factors make ideal glucose control a challenge. Control-to-range and control-to-target artificial pancreas devices (closed-loop artificial pancreas devices [C-APDs]) consist of a continuous glucose monitor, response algorithm, and insulin delivery device that work together to automate much of the glycemic management for an individual while continually adjusting insulin dosing toward a glycemic target. In this way, a C-APD can improve glycemic control and decrease the rate of hypoglycemia. The MiniMed 670G (Medtronic, Fridley, MN) system is currently the only Food and Drug Administration-cleared C-APD in the United States. In this system, insulin delivery is continually adjusted to a glucose concentration, and the patient inputs meal-time information to modify insulin delivery as needed. Data thus far suggest improved glycemic control and decreased hypoglycemic events using the system, with decreased need for patient self-management. Thus, the anticipated use of these devices is likely to increase dramatically over time. There are limited case reports of safe intraoperative use of C-APDs, but the Food and Drug Administration has not cleared any device for such use. Nonetheless, C-APDs may offer an opportunity to improve patient safety and outcomes through enhanced intraoperative glycemic control. Anesthesiologists should become familiar with C-APD technology to help develop safe and effective protocols for their intraoperative use. We provide an overview of C-APDs and propose an introductory strategy for intraoperative study of these devices.

MeSH terms

  • Algorithms
  • Anesthesia, Closed-Circuit / methods
  • Anesthesiology / methods
  • Anesthesiology / standards
  • Blood Glucose
  • Blood Glucose Self-Monitoring / methods
  • Diabetes Mellitus, Type 1 / blood
  • Diabetes Mellitus, Type 1 / therapy*
  • Equipment Design
  • Humans
  • Hyperglycemia
  • Hypoglycemia / therapy*
  • Hypoglycemic Agents / administration & dosage
  • Inpatients
  • Insulin / administration & dosage
  • Insulin Infusion Systems*
  • Monitoring, Ambulatory / methods
  • Outpatients
  • Pancreas, Artificial*
  • Perioperative Period*
  • Treatment Outcome

Substances

  • Blood Glucose
  • Hypoglycemic Agents
  • Insulin