Anesthesiology Manual:
Best Practices and Case Management

A large 2026 international study suggests that continuing metformin on the day of elective surgery may offer modest benefits for patients with type 2 diabetes mellitus, while no clear advantage or disadvantage was found for continuing or withholding SGLT2 inhibitors or GLP-1 receptor agonists. The findings come from a secondary analysis of the multinational MOPED (Management and Outcomes of Perioperative Care among European Diabetic Patients) study, published in the British Journal of Anaesthesia (Buggy et al.).  Why this study matters The perioperative management of glucose-lowering medications remains controversial. Different professional organizations recommend different approaches, particularly for newer medications such as: Metformin Sodium-glucose cotransporter-2 (SGLT2) inhibitors Glucagon-like peptide-1 (GLP-1) receptor agonists Stopping these medications may worsen glycemic control, while continuing some drugs has raised concerns about complications such as euglycemic diabetic ketoacidosis or delayed gastric emptying. Study overview Researchers analyzed data from the prospective MOPED study involving patients with type 2 diabetes undergoing elective surgery. Study population Nearly 5,000 patients undergoing elective surgery 89 hospitals 21 European countries Average age: approximately 64 years 57% male Median diabetes duration: 9 years Key findings Metformin Patients who continued metformin on the day of surgery experienced: Slightly more days alive and at home within 30 days after surgery (DAH-30) Lower rates of postoperative ketoacidosis Fewer episodes of hypoglycemia No reported cases of metformin-associated lactic acidosis After adjusting for differences in patient characteristics and surgical complexity, the benefit remained statistically significant but modest, approximately 0.5 additional days alive at home. SGLT2 inhibitors Researchers found: No significant improvement in the primary outcome (DAH-30) No increase in diabetic ketoacidosis in this cohort Sample size was relatively small, limiting firm conclusions The authors therefore recommend that current guideline recommendations regarding temporary withholding of SGLT2 inhibitors before surgery should remain unchanged until stronger evidence becomes available. GLP-1 receptor agonists […]

A new analysis published in the European Journal of Anaesthesiology has identified a significant association between higher positive perioperative fluid balance and the development of postoperative acute kidney injury (AKI) in patients undergoing elective colorectal surgery. The findings add to growing evidence that excessive fluid accumulation during the perioperative period may contribute to adverse postoperative outcomes and highlight the importance of individualized fluid management strategies. Acute kidney injury remains a major surgical complication Acute kidney injury is one of the most common postoperative complications and is associated with: Increased morbidity Longer hospital stays Higher healthcare costs Increased mortality risk Greater likelihood of long-term renal dysfunction Previous studies have shown that AKI occurs in approximately 13% of patients undergoing major abdominal surgery and is associated with substantially increased mortality. Despite this, optimal perioperative fluid management remains an area of ongoing debate. Study overview Researchers conducted a pre-planned secondary analysis of the multicentre POWER study, which evaluated outcomes in patients undergoing elective colorectal surgery across 80 hospitals in Spain. Study design Prospective observational cohort study 80 participating hospitals Recruitment period of two months 1,139 patients included Follow-up period of 30 days after surgery The primary objective was to examine whether perioperative fluid balance during the first 24 hours after surgery was associated with the risk of developing postoperative AKI. Key findings AKI occurred in 6.4% of patients Among the 1,139 patients included: 73 patients developed postoperative AKI Overall incidence was 6.4% Mild AKI occurred in 2.7% Moderate AKI occurred in 2.7% Severe AKI occurred in 1.0% Higher fluid balance increased risk Patients who developed AKI had a significantly greater positive fluid balance during the first 24 postoperative hours. Average 24-hour fluid balance: AKI patients: 1,780 mL Non-AKI patients: 1,038 mL The relationship persisted even after adjustment for important confounding factors. Fluid balance […]