Perioperative Management of Blood Glucose in Adults With Diabetes Mellitus

Perioperative management of blood glucose in adults with diabetes mellitus - UpToDate 20/03/17 21(22
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Perioperative management of blood glucose in adults with diabetes mellitus
Authors: Nadia A Khan, MD, MSc, William A Ghali, MD, MPH, Enrico Cagliero, MD
Section Editors: David M Nathan, MD, Stephanie B Jones, MD
Deputy Editor: Jean E Mulder, MD
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Feb 2017. | This topic last updated: Sep 30, 2016.
INTRODUCTION Diabetes mellitus is a common chronic disorder, affecting approximately 8 percent of the
United States population [1]. Patients with diabetes have an increased incidence of cardiovascular disease
and this, combined with the frequent microvascular complications of the disease, often translate into more
surgical interventions.
Careful assessment of patients with diabetes prior to surgery is required because of their complexity and high
risk of coronary heart disease, which may be relatively asymptomatic compared with the nondiabetic
population. Diabetes mellitus is also associated with increased risk of perioperative infection and
postoperative cardiovascular morbidity and mortality [2,3].
One key aspect of the perioperative management is glycemic control; complex interplay of the operative
procedure, anesthesia, and additional postoperative factors such as sepsis, disrupted meal schedules and
altered nutritional intake, hyperalimentation, and emesis can lead to labile blood glucose levels. A rational
approach to diabetes mellitus management allows the clinician to anticipate alterations in glucose and
improve glycemic control perioperatively [4].
This review will discuss the preoperative evaluation of patients with diabetes, general goals of glycemic
control, and management of blood glucose in the perioperative phase. The special circumstances of
glucocorticoid therapy and hyperalimentation are also reviewed. More details regarding glucose control in
hospitalized patients in general are found separately. (See "Management of diabetes mellitus in hospitalized
patients" and "Glycemic control and intensive insulin therapy in critical illness".)
PREOPERATIVE EVALUATION
Clinical evaluation The preoperative evaluation of any patient, including those with diabetes mellitus,
focuses on cardiopulmonary risk assessment and modification. Coronary heart disease is much more
common in individuals with diabetes than in the general population, and in addition, patients with diabetes
have an increased risk of silent ischemia [5,6]. Therefore, assessment of cardiac risk is essential in patients
with diabetes [3]. Other associated conditions, such as hypertension, obesity, chronic kidney disease,
cerebrovascular disease, and autonomic neuropathy, need to be assessed prior to surgery as these
conditions may complicate anesthesia and postoperative care. (See "Prevalence of and risk factors for
coronary heart disease in diabetes mellitus" and "Evaluation of cardiac risk prior to noncardiac surgery" and
"Anesthesia for the obese patient" and "Overview of post-anesthetic care for adult patients".)
All patients require a careful history and physical examination, with further evaluation required in certain
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individuals. Key elements of the initial assessment include the following:
Determination of the type of diabetes, since type 1 diabetes patients are at much higher risk of diabetic
ketoacidosis and must have basal insulin supplied at all times
Long-term complications of diabetes mellitus, including retinopathy, nephropathy, neuropathy, autonomic

neuropathy, coronary heart disease, peripheral vascular disease, and hypertension
Assessment of baseline glycemic control, including frequency of monitoring, average blood glucose
levels, range of blood glucose levels, and glycated hemoglobin (A1C) levels
Assessment of hypoglycemia, including frequency, timing, awareness, and severity
Detailed history of diabetes therapy, including insulin type, dose, and timing
Other pharmacologic therapy, including type of medication, dosing, and specific timing
Characteristics of surgery, including when the patient must stop eating prior to surgery, type of surgery
(major or minor), timing of the operative procedure, and duration of the procedure
Type of anesthetic, including epidural or regional versus general anesthesia (epidural or regional
anesthesia has minimal effects on glucose metabolism and insulin resistance) [7]
Laboratory Basic investigation should include a baseline electrocardiogram (ECG), assessment of renal
function (serum creatinine), A1C if not measured in previous four to six weeks, and blood glucose. ECG
abnormalities, such as abnormal q waves suggestive of previous myocardial infarction, and chronic kidney
disease are risk factors for major postoperative cardiac events. Further investigations including noninvasive
cardiac testing should be considered on an individual basis. (See "Evaluation of cardiac risk prior to
noncardiac surgery".)
If not previously assessed within the last three months, an A1C level should be measured. A1C levels will
permit the determination of chronic glycemic control, and this is an important element in determining
adequacy of current glycemic management, especially insulin dose, in insulin-requiring patients. There is
some suggestion that elevated A1C levels predict a higher rate of postoperative adverse events, including
infections, myocardial infarction, and mortality [8-12]. As an example, in an analysis of 3089 patients
undergoing elective coronary artery bypass grafting, who had A1C measured as part of routine preoperative
labs, higher A1C was associated with an increased incidence of death, myocardial infarction, and sternal
wound infection (odds ratio [OR] approximately 1.4 per unit increase in A1C) [10]. Specifically, there was an
increased risk of death (OR 4.41) and sternal wound infection (OR 5.29) for patients with A1C values above
8.6 and 7.8 percent (70.5 and 61.7 mmol/mol), respectively.
Baseline glucose levels can also help to stratify risk for postoperative wound infections [13,14]. Elevated
preoperative glucose levels (>200 mg/dL [>11 mmol/L]) were associated with deep wound infections in a case
control study (OR 10.2, 95% CI 2.4-43) [13].
EFFECT OF SURGERY ON GLUCOSE CONTROL Surgery and general anesthesia cause a

neuroendocrine stress response with release of counterregulatory hormones such as epinephrine, glucagon,
cortisol, and growth hormone, and of inflammatory cytokines such as interleukin-6 and tumor necrosis factor-
alpha. These neurohormonal changes result in metabolic abnormalities including insulin resistance,
decreased peripheral glucose utilization, impaired insulin secretion, increased lipolysis and protein
catabolism, leading to hyperglycemia and even ketosis in some cases [15-24].
The magnitude of counterregulatory hormone release varies per individual and is influenced by the type of
anesthesia (general anesthesia is associated with larger metabolic abnormalities as compared with epidural
anesthesia), the extent of the surgery (cardiovascular bypass surgery resulting in significantly higher degree
of insulin resistance), and additional postoperative factors such as sepsis, hyperalimentation, and
glucocorticoid use. The hyperglycemic response to these factors may be attenuated by the lack of caloric
intake during and immediately after surgery, making the final glycemic balance difficult to predict.
GOALS OF GLYCEMIC CONTROL
General goals The goals of perioperative diabetes management include:
Avoidance of hypoglycemia
Prevention of ketoacidosis/hyperosmolar states
Maintenance of fluid and electrolyte balance
Avoidance of marked hyperglycemia
Hypoglycemia is a potentially life-threatening complication of poor perioperative metabolic control. Severe

hypoglycemia (ie, serum glucose concentration <40 mg/dL [2.2 mmol/L]), even for short periods of time, can
induce arrhythmias, other cardiac events, or transient cognitive deficits. Hypoglycemia and subsequent
neuroglucopenia can be difficult to detect in sedated or anesthetized patients. (See 'Hypoglycemia' below.)
Patients with type 1 diabetes mellitus are insulin deficient and are prone to developing ketosis and acidosis. A
common mistake is to manage these patients like type 2 diabetes patients who are not ketosis prone and, for
example, holding long-acting insulin if the glucose level is in the normal range, with the consequent risk of
ketoacidosis. Similarly, failure to provide pre-meal rapid-acting insulin for persons with type 1 diabetes will
result in unacceptable post-meal glucose excursions. Type 2 diabetes patients are susceptible to developing
hyperosmolar hyperglycemic state (also known as nonketotic hyperosmolar state) that may lead to severe
volume depletion and neurologic complications, and they may develop ketoacidosis in the setting of extreme
stress. (See "Diabetic ketoacidosis and hyperosmolar hyperglycemic state in adults: Clinical features,
evaluation, and diagnosis".)
Patients with diabetes are more susceptible to infection in the postoperative period [25]. Observational
studies show an association between preoperative or perioperative hyperglycemia in diabetic patients and an
increased risk of postoperative infection [13,26,27] (see "Susceptibility to infections in persons with diabetes
mellitus", section on 'Are diabetics more susceptible to infection?'). Hyperglycemia can cause volume and
electrolyte disturbances mediated by osmotic diuresis and may also result in caloric and protein loss in under-
insulinized patients.
Glycemic targets Beyond avoidance of marked hyperglycemia and hypoglycemia, the optimal
perioperative glucose targets are unclear. Although there are varying opinions on what the target blood
glucose should be, in our practice, we aim to keep glucose readings between 140 and 200 mg/dL (7.8 to 11
mmol/L). In a meta-analysis of 12 randomized trials (1403 patients with diabetes) comparing intensive (<120
or <150 mg/dL [<6.7 or <8.3 mmol/L]) versus conventional (variable) glycemic control in the perioperative
period, intensive glycemic control perioperatively was not associated with any reductions in infectious
complications, cardiovascular events, or mortality, but was associated with increased risk of hypoglycemia
[28]. Among the trials, the mean difference in achieved blood glucose levels between the intensive and
conventional groups ranged from -13 to -91 mg/dL (0.72 to 5.0 mmol/L).
Diabetes guideline bodies recommend glycemic targets of between 110 and 180 mg/dL (6.1 to 10 mmol/L) for
non-critically ill hospitalized patients [29,30]. However, a less stringent glucose target (<200 mg/dL [11
mmol/L]) may be considered depending on risk for hypoglycemia and also potentially in the general patient
population (given the acknowledged lack of evidence to support more stringent targets). The risk of
hypoglycemia can be reduced by frequent glucose monitoring and carefully designed management protocols.
The American Diabetes Association (ADA) has endorsed a target glucose range for the perioperative period
of 80 to 180 mg/dL (4.4 to 10 mmol/L) [31]. (See "Management of diabetes mellitus in hospitalized patients",
section on 'Glycemic targets' and "Glycemic control and intensive insulin therapy in critical illness".)
PERIOPERATIVE PHASE Several strategies exist to maintain target range glucose levels perioperatively,
but there is no consensus as to the optimal strategy [32,33]. Most protocols for insulin administration are
formulated by expert opinion and personal experience. The strategies described below, while sensible, have
not been proven to optimally reduce outcomes of morbidity, mortality, and hospital length of stay. The role of
insulin infusions has not been clarified, but these strategies are often expensive, labor intensive, and even
impossible at some hospitals. Ultimately, even well coordinated plans for diabetic management are dynamic,
being influenced by predictable and sometimes unpredictable events. Decisions of which regimens to utilize
and when will depend upon individual patients, hospital settings and resources, and the clinician's own
judgment.
Ideally, all patients with diabetes mellitus should have their surgery as early as possible in the morning to
minimize the disruption of their management routine while being nil per os (NPO).
Type 2 diabetes treated with diet alone Generally, patients with type 2 diabetes managed by diet alone
do not require any therapy perioperatively. Supplemental short- (eg, regular) or rapid-acting (eg, lispro,
aspart, or glulisine) insulin (table 1) may be given as correction insulin in patients whose glucose levels rise
over the desired target. In this setting, it is typically administered every six hours. (See 'Correction insulin'
below.)
Blood glucose levels should be checked preoperatively and soon after the surgery. For long surgeries (more
than two hours) or surgeries associated with expected high glucose levels (eg, coronary artery bypass
grafting, organ transplants with steroid use) intraoperative glucose testing every one to two hours should be
performed either by laboratory or point of care testing (using a blood glucose meter). Fingerstick glucose
levels are less reliable in patients who are critically ill, are on vasopressor agents, or hypotensive, and venous
or arterial blood and laboratory testing should be used in these cases [34]. Intravenous (IV) solutions do not
require dextrose if insulin is not given.
Type 2 diabetes treated with oral hypoglycemic agents/noninsulin injectables Patients with type 2
diabetes who take oral hypoglycemic drugs or noninsulin injectables (eg, glucagon-like peptide-1 [GLP-1]
analogs exenatide, liraglutide, albiglutide, dulaglutide) are advised to continue their usual routine of
antidiabetic medications until the morning of surgery. On the morning of surgery, they should hold their oral
hypoglycemic and noninsulin injectable drugs.
Sulfonylureas increase the risk of hypoglycemia

Metformin is contraindicated in conditions that increase the risk of renal hypoperfusion, lactate
accumulation, and tissue hypoxia
Thiazolidinediones may worsen fluid retention and peripheral edema and could precipitate congestive
heart failure
Sodium-glucose cotransporter 2 (SGLT2) inhibitors increase the risk of hypovolemia. There have also
been reports of acute kidney injury and euglycemic diabetic ketoacidosis in patients with type 2 diabetes
taking SGLT2 inhibitors.
Other agents like dipeptidyl peptidase IV (DPP-IV) inhibitors and GLP-1 analogs could alter
gastrointestinal (GI) motility and worsen the postoperative state.
(See "Initial management of blood glucose in adults with type 2 diabetes mellitus", section on 'Initial
pharmacologic therapy' and "Management of persistent hyperglycemia in type 2 diabetes mellitus", section on
'Treatment options'.)
Most patients with good glycemic control (glycated hemoglobin [A1C] <7.0 percent [53 mmol/mol]) on oral or
noninsulin injectable agents will not need insulin for short surgical procedures. Capillary fingerstick blood
glucose should be monitored every two hours, using a blood glucose meter. For patients who develop
hyperglycemia, supplemental short- or rapid-acting insulin (table 1) may be administered subcutaneously
(typically every six hours), based on frequently (every one to two hours) measured glucose levels which are
often obtained on capillary "fingerstick" samples (table 2) (see 'Correction insulin' below). In patients who are
critically ill, are on vasopressor agents, or hypotensive, venous or arterial blood and laboratory testing should
be used instead of fingerstick samples and a blood glucose meter.
Correction insulin is administered until the patient is eating and either can resume oral agents or a basal-
bolus insulin regimen is initiated. Most antidiabetic medications can be restarted after surgery when patients
resume eating, with the exception of metformin, which should be delayed in patients with suspected renal
hypoperfusion until documentation of adequate renal function.
Type 1 or insulin-treated type 2 diabetes
Short procedures Generally, patients who use insulin can continue with subcutaneous insulin
perioperatively (rather than an insulin infusion) for procedures that are not long and complex (eg, less than
two hours) [4,23,35-40].
For minor, early morning procedures where breakfast is likely only delayed, patients may delay taking their
usual morning (short- or rapid-acting insulin) insulin until after the surgery and before eating. However,
patients who take once-daily long-acting insulin (eg, glargine) or who use continuous insulin infusion (insulin
pump) may continue basal insulin without any change to their usual regimen, as long as the basal insulin
dose has been correctly calculated. In patients whose basal rate is calculated to keep the blood glucose in
normal or low-normal ranges or when there is history of low glucose measures as an outpatient, we often
reduce the dose (or rate) by 10 to 20 percent to avoid any chance of preoperative hypoglycemia. If patients
need to eat to treat hypoglycemia, surgery may be cancelled.
For patients undergoing morning procedures where breakfast and possibly lunch are likely to be missed or for
surgeries that take place later in the day:
Omit any short- or rapid-acting insulin on the morning of surgery.
For patients who take two types of insulin (intermediate or long and rapid or short-acting) only in the
morning, give between one-half to two-thirds of their usual total morning insulin dose (both types of
insulin) as intermediate or long-acting insulin to provide basal insulin during the procedure and prevent
ketosis.
For patients who take insulin (intermediate or long and rapid or short-acting) two or more times per day,
give between one-third to one-half of the total morning dose (both types of insulin) as intermediate- or
long-acting insulin.
Patients on continuous insulin infusion (insulin pump) may continue with their usual basal infusion rate,
assuming that the catheter and pump can remain safely in place during the procedure.
Start dextrose containing IV solution (D5 with either water or with one-half isotonic saline) at a rate of 75
to 125 cc/hour to provide 3.75 to 6.25 g glucose/hour to avoid the metabolic changes of starvation [35-
40].
Check blood sugars either by fingerstick or with a laboratory method every hour, and more frequently if
blood glucose is <100 mg/dL (5.5 mmol/L) or if the rate of fall is rapid. Fingerstick glucose levels are less
reliable in patients who are critically ill, are on vasopressor agents, or hypotensive, and venous or arterial
blood and laboratory testing should be used in these cases.
For patients who develop hyperglycemia, supplemental short or rapid-acting insulin (table 1) may be
administered subcutaneously, based on frequently measured glucose levels which are often obtained on
capillary "fingerstick" samples. (See 'Correction insulin' below.).
Some clinicians switch their patients taking long-acting insulin (eg, glargine) to an intermediate-acting insulin
one to two days prior to surgery because of a perceived potential increased risk for hypoglycemia with the
former, and because the effects of dose changes can be seen more rapidly with the latter. However, if the
basal insulin is correctly calibrated, it is reasonable to continue the long-acting insulin while the patient is nil
per os (NPO) and on IV dextrose. There are no available data to support one approach over the other.
In a patient with type 1 diabetes (less often type 2) who has frequent hypoglycemia or fasting blood glucose
levels in the lower end of the normal range, it may be prudent to reduce the night time (supper or bedtime)
long- or intermediate-acting insulin by 10 to 20 percent on the night prior to surgery to prevent hypoglycemia.
Basal metabolic needs utilize approximately one-half of an individual's insulin even in the absence of oral
intake; thus, patients should continue with some insulin even when not eating [41]. This is mandatory in type
1 diabetes to prevent ketoacidosis.
Long and complex procedures IV insulin is usually required for long and complex procedures (eg,
coronary artery bypass graft, renal transplant, or prolonged neurosurgical operations). Studies comparing
subcutaneous insulin administration versus IV infusion have found a marked increase in variability of the
glucose concentration when using the subcutaneous route [41,42]. This variability in plasma insulin has been
attributed to the varying degrees of insulin absorption in the setting of vasoconstriction and hypoperfusion and
hypothermia.
The safety of IV insulin infusion in highly monitored settings has been demonstrated by many studies [35-45].
In addition, insulin infusions are more readily titrated because the half-life of IV insulin is short (ie, 5 to 10
minutes), allowing for more precise glucose control.
IV insulin regimens require close monitoring of blood glucose (no less than hourly and more often if blood
glucose levels are <100 mg/dL [5.5 mmol/L] or if the rate of fall is rapid, suggesting hypoglycemia could occur
quickly) and electrolytes as well as appropriate interpretation by well-trained staff. Intraoperative glucose
testing should be performed either by laboratory or point of care testing. Fingerstick glucose levels are less
reliable in patients who are critically ill, are on vasopressor agents, or hypotensive, and venous or arterial
blood and laboratory testing should be used in these cases.
Generally, insulin infusions should be started early in the morning prior to surgery to allow time to achieve
glycemic control. There are numerous IV insulin infusion algorithms published in the literature, with insulin
and glucose solutions being infused separately or as a combined glucose insulin potassium (GIK) solution
[35-45]. (See "Interactive diabetes case 12: Perioperative management of a 67-year-old man with type 2
diabetes who undergoes coronary artery bypass surgery".)
Glucose insulin potassium infusion The GIK drip is a single solution infusion that includes 500 mL
of 10 percent dextrose, 10 mmol of potassium chloride, and 15 units of short-acting insulin [46]. The solution
is infused at an initial rate of 100 mL/hour. The solution can be altered depending on the blood glucose
measured every two hours by adding or subtracting five units of insulin. Potassium is added to prevent
hypokalemia and is monitored at six hour intervals.
This regimen is safe because the insulin and glucose are given together, but is more cumbersome and may
require frequent changes of IV solution. The blood glucose should be monitored frequently, at least every two
hours. The problem with this approach is that if glucose levels run low, based upon the target levels, and the
infusion is stopped, patients with type 1 diabetes can quickly become ketotic.
Separate insulin and glucose intravenous solutions With this regimen, dextrose is administered
at approximately 5 to 10 g of glucose/hour, and a separate insulin infusion is given using short-acting insulin.
Most type 1 diabetes patients require an infusion at a rate of 1 to 2 units/hour, while more insulin resistant
type 2 diabetes patients can require higher insulin rates.
A commonly followed algorithm calculates the initial rate by dividing the blood glucose level (in mg/dL) by 100
and then rounding the result in units/hour (eg, glucose of 210, 210 divided by 100 = 2.1 units/hour) [39].
Capillary glucose levels should be checked every one to two hours and the insulin infusion adjusted (eg,
glucose 120 to 160 increase by 0.5 units/hour, 160 to 200 increase by 1.0 units/hour, >200 increase by 2.0
units/hour). In case of hypoglycemia, the insulin infusion can be decreased; however, the temptation to stop
the insulin infusion should be avoided in type 1 diabetes patients to avoid ketosis. The insulin infusion can be
decreased to 0.5 units/hour and the glucose infusion rate increased to maintain glucose targets.
The rate of insulin infusion may be titrated depending on the procedure and the degree of insulin resistance.
For coronary artery bypass procedures, the insulin requirements may increase up to 10-fold, especially after
recovery from the hypothermic period, necessitating an increase in the initial insulin rate by three to five times
[47].
This regimen is flexible and does not require changes of entire solution bags like the GIK infusion. However,
there is a concern that hypoglycemia will develop if the glucose infusion is inadvertently obstructed or held.
POSTOPERATIVE PHASE Generally the preoperative diabetes treatment regimen (oral agents, oral
agents plus insulin, or basal-bolus insulin) may be reinstated once the patient is eating well. However, there
are a few caveats for certain oral hypoglycemic agents.
Metformin should not be restarted in patients with renal insufficiency, significant hepatic impairment, or
congestive heart failure.
Sulfonylureas stimulate insulin secretion and may cause hypoglycemia; they should be started only after
eating has been well established. A step-up approach can be used for patients on high dose
sulfonylureas, starting at low doses and adjusting them until the usual dose is reached.
Thiazolidinediones should not be used if patients develop congestive heart failure or problematic fluid
retention, or if there are any liver function abnormalities.
If an insulin infusion has been used, it should be continued in patients who do not resume eating
postoperatively. Once it seems likely that solid food will be tolerated, the patient can be switched to
subcutaneous insulin, and then the insulin infusion can be discontinued. Because of the short half-life of
intravenous (IV) regular insulin, the first dose of subcutaneous insulin must be given before discontinuation of
the IV insulin infusion. If intermediate or long-acting insulin is used, it should be given two to three hours prior
to discontinuation, whereas short- or rapid-acting insulin should be given one to two hours prior to stopping
the infusion. (See "Interactive diabetes case 12: Perioperative management of a 67-year-old man with type 2
diabetes who undergoes coronary artery bypass surgery".)
Patients who were taking subcutaneous insulin in the early postoperative phase, before alimentation is
restarted, should continue this treatment along with IV dextrose (5 to 10 g of glucose/hour = 100 to 200
mL/hour of dextrose in water or in one-half isotonic saline solution) to prevent hypoglycemia. Once the patient
is able to tolerate food, outpatient or other insulin regimens can be titrated back.
More details regarding the management of diabetes in hospitalized patients are found separately. (See
"Management of diabetes mellitus in hospitalized patients".)
CORRECTION INSULIN Varying doses of short or rapid-acting insulin can be added to usual premeal
short- or rapid-acting insulin in patients on basal-bolus insulin regimens to correct premeal glucose
excursions. In this setting, the additional insulin is referred to as correction insulin. Corrective insulin
typically is given when glucose levels are >150 mg/dL (8.3 mmol/L), and the amount of insulin depends upon
the degree of insulin sensitivity of the patient, caloric intake, and the glycemic target (table 2) (see 'Glycemic
targets' above). Older, lean type 1 diabetes patients or individuals with renal or liver failure are usually
considered to be insulin sensitive, while obesity or treatment with glucocorticoids are usually associated with
an insulin resistant state. Smaller doses of insulin are given at bedtime to avoid nocturnal hypoglycemia.
Many different regimens have been used, with no studies demonstrating the superiority of one over the
others. Since there is a large patient to patient variability in terms of insulin sensitivity and response to clinical
changes, the absolute dose choice is empirical and most importantly, frequent (daily) adjustments based on
glucose levels need to be made.
When used as sole methods of insulin delivery, sliding scales of insulin can be problematic, since they delay
administration of insulin until hyperglycemia is present and frequently cause wide fluctuations in the serum
glucose as they only react to past glucose concentrations. Thus, correction insulin should never be the sole
insulin regimen in type 1 diabetes because ketosis can occur before significant hyperglycemia is present. In
all patients with type 1 and in some insulin treated patients with type 2 diabetes, small doses of short (or
rapid)-acting (correction) insulin can be given before meals together with their prandial insulin, and at bedtime
as needed, or alternatively in patients who are nil per os (NPO), every six hours, supplementing pre-
scheduled basal and prandial insulin (basal-bolus insulin) to prevent hyperglycemia.
This approach is supported by the results of a randomized trial of sliding scale regular insulin versus a basal-
bolus insulin regimen (glargine once daily and glulisine before meals) in 211 patients with type 2 diabetes
admitted to the hospital for general elective or emergency surgery [48]. Oral antidiabetic agents were
discontinued on admission. Patients randomly assigned to sliding scale regular insulin alone had significantly
higher mean glucose concentrations (172 versus 145 mg/dL [9.6 versus 8.0 mmol/L]) and a significantly
higher frequency of the composite outcome (24.3 versus 8.6 percent), which included wound infection,
pneumonia, bacteremia, respiratory failure, and acute renal failure. Among the individual components of the
composite outcome, higher frequency of wound infection (10.3 versus 2.9 percent) was the only outcome that
reached borderline statistical significance (p = 0.05).
Although correction insulin alone should not be used as the sole treatment for patients with type 1 or insulin-
treated type 2 diabetes, correction insulin alone may be used as initial insulin therapy or as a dose-finding
strategy in patients with type 2 diabetes previously treated at home with diet or an oral agent, who will not be
eating regularly during hospitalization. In this setting, it is typically administered every six hours as regular or
rapid-acting insulin, until the patient is eating and either can resume oral agents or a basal-bolus regimen is
initiated. (See "Management of diabetes mellitus in hospitalized patients", section on 'Correction insulin'.)
HYPOGLYCEMIA Hypoglycemia is an important problem in type 1 diabetes, in which the risk of severe
hypoglycemia is increased more than threefold [49]. Less commonly, hypoglycemia may also affect patients
with type 2 diabetes who take a sulfonylurea or a meglitinide or who use insulin. Prevention of severe
hypoglycemia requires the recognition of early symptoms and signs by the patient (and by those around
them). Avoiding hypoglycemia during anesthesia and in the postoperative phase is important because
hypoglycemic symptoms are virtually impossible for the sedated patient to sense and, similarly, its signs are
difficult for health care providers to detect. Thus, the goals in the perioperative setting are to preoperatively
identify patients at highest risk for hypoglycemia, appropriately adjust diabetes treatment preoperatively to
prevent its occurrence, and monitor for any episodes of hypoglycemia by measuring glucose levels to ensure
prompt treatment. Patients at particularly high risk for perioperative hypoglycemia include patients with tight
glycemic control, labile blood glucoses, or history of frequent hypoglycemia [32].
In the perioperative setting, hypoglycemia can be detected through monitoring of blood glucose levels, which
are typically checked every one to two hours during surgery (for patients treated with insulin or insulin
secretagogues). In patients with diabetes, hypoglycemia is defined as all episodes of an abnormally low
plasma glucose concentration (with or without symptoms) that expose the individual to harm. Although the
cut-off value has been debated, clinicians should become concerned about the possibility of hypoglycemia in
a perioperative patient at a glucose level 70 mg/dL (3.9 mmol/L). Depending upon the blood glucose level,
defensive options include repeating the measurement more frequently, decreasing the rate of an insulin
infusion or subsequent dose of subcutaneous insulin, and/or administering intravenous (IV) dextrose. For a
sedated, anesthetized patient with a blood glucose of <70 mg/dL, we typically administer IV dextrose (25 g)
and repeat blood glucose measurements in 5 to 10 minutes. (See "Hypoglycemia in adults: Clinical
manifestations, definition, and causes", section on 'Definitions'.)
After recovery from anesthesia or sedation, hypoglycemia may be suspected based upon symptoms,
including tremor, palpitations, anxiety, sweating, hunger, and paresthesias. The hypoglycemic thresholds at
which these symptoms occur are very variable. In patients with diabetes, these symptoms of hypoglycemia
may occur at glucose levels of <70 mg/dL (3.9 mmol/L). Hypoglycemia can also cause cognitive dysfunction,
which may occur at plasma glucose concentrations below 60 mg/dL (3.3 mmol/L). More severe neurologic
symptoms, including obtundation, seizures, and coma, occur with progressive hypoglycemia. The glycemic
thresholds for these responses shift to higher plasma glucose concentrations in patients with poorly controlled
diabetes and to lower plasma glucose concentrations in patients with repeated episodes of hypoglycemia,
such as may be associated with intensive therapy of diabetes. (See "Hypoglycemia in adults: Clinical
manifestations, definition, and causes", section on 'Clinical manifestations'.)
In the awake patient with a normal swallowing mechanism and gag reflex, symptomatic hypoglycemia is
typically treated with at least 15 g of carbohydrates (glucose tablet, sweetened fruit juice). In patients unable
to take anything by mouth, hypoglycemia can be treated by giving 25 g of 50 percent glucose (dextrose)
intravenously. The treatment of hypoglycemia is reviewed in more detail elsewhere. (See "Management of
hypoglycemia during treatment of diabetes mellitus".)
SPECIAL CONSIDERATIONS
Glucocorticoid therapy Glucocorticoids are used for the treatment of many disorders and are often given
as an antiemetic, or in "stress" doses perioperatively to prevent adrenal insufficiency. Glucocorticoids worsen
preexisting diabetes mellitus and may precipitate steroid-induced hyperglycemia in patients without pre-
existing diabetes. However, the magnitude of the hyperglycemic response depends on the dose of
glucocorticoids. As an example, in one randomized trial of 185 patients with and without diabetes undergoing
non-cardiac surgery, there was little hyperglycemic response with low, antiemetic dose dexamethasone (4 to
8 mg intravenous [IV]) in diabetic patients, and only a slightly greater response in non-diabetic patients [50].
However, higher doses of dexamethasone (1 mg/kg) or methylprednisolone (15 to 30 mg/kg) were associated
with large increases in glucose levels in patients having cardiac surgery [51]. (See "The management of the
surgical patient taking glucocorticoids" and "Major side effects of systemic glucocorticoids", section on
'Glucose metabolism'.)
Oral hypoglycemic medications can be used in patients with a constant dose of steroids and minimal
elevation in blood glucose; insulin is necessary for those whose glucose levels are elevated (>200 g/dL or 11
mmol/L) and for patients who are started on large doses of steroids or that have their dose increased
significantly [52]. While there are no guidelines for specific insulin regimens in patients on oral or IV steroids,
considerations should be given to the specific steroids used and their doses. Morning prednisone increases
glucose levels for 6 to 10 hours, with values coming down during the late afternoon and night, while longer-
acting steroids or twice-daily dosing will require more prolonged insulin coverage.
For morning prednisone treated patients (up to 60 mg daily), a morning dose of intermediate insulin could
achieve good control. Twice-daily intermediate-acting insulin with short-acting insulin given in a subcutaneous
sliding scale may be needed to achieve glucose control in patients using longer-acting steroids or patients on
steroids dosed twice daily. A two- to threefold increase in the total daily insulin dose is frequently needed in
patients on high-dose steroid therapy. For such patients, a variable rate insulin and glucose infusion may be
appropriate, especially with variable dosing of glucocorticoids. Studies examining these treatment strategies
are lacking and the recommendations presented are based primarily on simplicity of execution.
Hyperalimentation Total parenteral nutrition (TPN) and nasogastric enteral feeds are commonly used in
patients who are malnourished or severely ill. TPN will often increase the serum blood glucose and
necessitate large doses of insulin to maintain glycemic control in diabetic patients.
Some investigators recommend using a variable rate insulin infusion when the patient is first started on TPN
[52]. Once the patient is on a stable infusion rate of TPN, he/she may have the daily requirement of insulin
directly added to the TPN solution bag. As an example, if the patient requires 20 units of insulin per 24 hours,
add 20 units of short-acting insulin in the TPN solution that is administered continuously over 24 hours. A
subcutaneous insulin sliding scale using short-acting insulin may be used initially to identify the 24-hour
https://www.uptodate.com/contents/perioperative-management-of-e=search_result&search=diabetes%20surgery&selectedTitle=1~150 Pgina 10 de 18
insulin requirement if insulin infusion is not feasible, and should be converted to a twice per day intermediate-
acting insulin if the TPN solution and rate are stable. TPN orders should always include an order to substitute
dextrose infusion and recalibrate insulin dosing if the TPN is interrupted for more than an hour.
For nasogastric feeds administered continuously over 24 hours, either a variable rate IV insulin infusion or
twice-daily intermediate-acting insulin plus sliding scale short-acting insulin every four to six hours may be
administered. Changes in insulin regimen must precede any changes in nasogastric feeding regimens (ie,
changes from 24-hour infusion to three times a day bolus feeds). As with TPN, interruption of continuous
enteral feeding for more than an hour will require IV dextrose to prevent hypoglycemia and recalibration of
insulin dosing. Thus, good communication between the surgeon, dietitian, and the person managing diabetes
care is important.
Emergency procedures When emergency surgery is required in a patient with diabetes whose glucose
levels are very high (for example, greater than 250 mg/dL [13.9 mmol/L]) or low enough to threaten
hypoglycemia (<100 mg/dL [5.5 mmol/L]), blood glucose levels should be monitored with fingerstick or whole
venous blood methods at least every hour, and more frequently for blood glucose levels <70 mg/dL (3.9
mmol/L). Many patients with type 1 diabetes and very elevated glucose levels may be managed most
conveniently with an IV insulin infusion through a reliable IV access.
For patients with type 2 diabetes and elevated blood glucose levels (>250 mg/dL [13.9 mmol/L]) who require
emergency surgery, we treat with an IV insulin infusion or subcutaneous insulin. For long procedures, an
insulin infusion is preferred. If the patient had been using a long-acting basal insulin (eg, glargine) once daily
or a continuous infusion of short- or rapid-acting insulin (insulin pump), it should be continued along with the
IV insulin infusion or additional corrective subcutaneous insulin.
SOCIETY GUIDELINE LINKS Links to society and government-sponsored guidelines from selected
countries and regions around the world are provided separately. (See "Society guideline links: Diabetes
mellitus in adults".)
SUMMARY AND RECOMMENDATIONS Several strategies exist to maintain target range glucose levels
perioperatively, but there is no consensus as to the optimal strategy. The strategies described below, while
sensible, have not been proven to optimally reduce outcomes of morbidity, mortality, and hospital length of
stay. Many specific issues require further investigation, including: optimal target range (although achieving
normoglycemia appears to have no consistent mortality benefit), regimen of insulin administration, and the
special circumstances of glucocorticoid use and hyperalimentation. Most protocols for insulin administration
are formulated by expert opinion and personal experience.
All patients require a careful preoperative history and physical examination, with further evaluation
required in certain individuals. Basic laboratory investigation should include a baseline electrocardiogram
(ECG), assessment of renal function (serum creatinine), glycated hemoglobin (A1C) if not measured in
previous four to six weeks, and blood glucose (see 'Preoperative evaluation' above). Associated
conditions, such as coronary heart disease, hypertension, obesity, chronic kidney disease,
cerebrovascular disease, and autonomic neuropathy, need to be assessed prior to surgery as these
conditions may complicate anesthesia and postoperative care. (See "Prevalence of and risk factors for
coronary heart disease in diabetes mellitus" and "Evaluation of cardiac risk prior to noncardiac surgery"
and "Anesthesia for the obese patient".)
The goals of perioperative diabetic management include avoidance of hypoglycemia, prevention of
ketoacidosis, maintenance of fluid and electrolyte balance, and avoidance of marked hyperglycemia.
(See 'General goals' above.)
There are few studies evaluating the optimal intraoperative blood glucose level for patients with diabetes.
During surgical procedures and in the postoperative phase, we aim to keep the glucose readings
between 140 and 200 mg/dL (7.8 to 11 mmol/L). For patients who are eating, we aim for a fasting
glucose of <140 mg/dL (7.8 mmol/L) with random glucose readings below 180 mg/dL (<10 mmol/L).
Glycemic targets must take into account the individual patient's situation and whether these goals can be
safely achieved within each individual hospital system. (See 'Glycemic targets' above.)
Ideally, all patients with diabetes mellitus should have their surgery prior to 9 AM to minimize the
disruption of their management routine while being nil per os (NPO). (See 'Perioperative phase' above.)
For short procedures, patients with type 2 diabetes managed by diet alone may not require any therapy
perioperatively. Supplemental short- (eg, regular) or rapid-acting (eg, lispro, aspart, or glulisine) insulin
(table 1) may be given (typically every six hours) to patients whose glucose levels rise over the desired
target (table 2). (See 'Type 2 diabetes treated with diet alone' above and 'Correction insulin' above.)
Patients with type 2 diabetes who take oral hypoglycemic drugs or noninsulin injectables (eg, glucagon-
like peptide-1 [GLP-1] analogs [exenatide, liraglutide]) are advised to hold their oral hypoglycemic and
noninsulin injectable drugs on the morning of surgery. For patients who develop hyperglycemia,
supplemental short or rapid-acting insulin (table 1) may be administered subcutaneously (typically every
six hours), based on frequently (every one to two hours) measured glucose levels which are often
obtained on capillary "fingerstick" samples (table 2). Correction insulin is administered until the patient is
eating and either can resume oral agents/noninsulin injectables or a basal-bolus insulin regimen is
initiated. (See 'Type 2 diabetes treated with oral hypoglycemic agents/noninsulin injectables' above and
'Correction insulin' above.)
Generally patients who use insulin can continue with subcutaneous insulin perioperatively at a reduced
dose (rather than an insulin infusion) for procedures that are not long and complex (eg, no more than
one or two missed meals). However, intravenous (IV) insulin is usually required for long and complex
procedures (eg, coronary artery bypass graft, renal transplant, or prolonged neurosurgical operations).
(See 'Type 1 or insulin-treated type 2 diabetes' above.)
Generally the preoperative diabetes treatment regimen (oral agents, noninsulin injectables, oral agents
plus insulin, or basal-bolus insulin) may be reinstated once the patient is eating well. However, there are
a few caveats for certain oral hypoglycemic agents. (See 'Postoperative phase' above.)
Glucose control in critically ill patients is discussed separately. (See "Glycemic control and intensive
insulin therapy in critical illness".)
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REFERENCES
1. Centers for Disease Control and Prevention. National diabetes fact sheet: national estimates and
general information on diabetes and prediabetes in the United States, 2011.
http://www.cdc.gov/diabetes/pubs/pdf/ndfs_2011.pdf (Accessed on June 04, 2012).

2. Malone DL, Genuit T, Tracy JK, et al. Surgical site infections: reanalysis of risk factors. J Surg Res
2002; 103:89.
3. Lee TH, Marcantonio ER, Mangione CM, et al. Derivation and prospective validation of a simple index
for prediction of cardiac risk of major noncardiac surgery. Circulation 1999; 100:1043.
4. Jacober SJ, Sowers JR. An update on perioperative management of diabetes. Arch Intern Med 1999;
159:2405.
5. Stamler J, Vaccaro O, Neaton JD, Wentworth D. Diabetes, other risk factors, and 12-yr cardiovascular
mortality for men screened in the Multiple Risk Factor Intervention Trial. Diabetes Care 1993; 16:434.
6. Kannel WB, McGee DL. Diabetes and cardiovascular risk factors: the Framingham study. Circulation
1979; 59:8.
7. Brandt M, Kehlet H, Binder C, et al. Effect of epidural analgesia on the glycoregulatory endocrine
response to surgery. Clin Endocrinol (Oxf) 1976; 5:107.
8. Dronge AS, Perkal MF, Kancir S, et al. Long-term glycemic control and postoperative infectious
complications. Arch Surg 2006; 141:375.
9. Sato H, Carvalho G, Sato T, et al. The association of preoperative glycemic control, intraoperative
insulin sensitivity, and outcomes after cardiac surgery. J Clin Endocrinol Metab 2010; 95:4338.
10. Halkos ME, Puskas JD, Lattouf OM, et al. Elevated preoperative hemoglobin A1c level is predictive of
adverse events after coronary artery bypass surgery. J Thorac Cardiovasc Surg 2008; 136:631.
11. Alserius T, Anderson RE, Hammar N, et al. Elevated glycosylated haemoglobin (HbA1c) is a risk marker
in coronary artery bypass surgery. Scand Cardiovasc J 2008; 42:392.
12. Stryker LS, Abdel MP, Morrey ME, et al. Elevated postoperative blood glucose and preoperative
hemoglobin A1C are associated with increased wound complications following total joint arthroplasty. J
Bone Joint Surg Am 2013; 95:808.
13. Trick WE, Scheckler WE, Tokars JI, et al. Modifiable risk factors associated with deep sternal site
infection after coronary artery bypass grafting. J Thorac Cardiovasc Surg 2000; 119:108.
14. Jmsen E, Nevalainen P, Eskelinen A, et al. Obesity, diabetes, and preoperative hyperglycemia as
predictors of periprosthetic joint infection: a single-center analysis of 7181 primary hip and knee
replacements for osteoarthritis. J Bone Joint Surg Am 2012; 94:e101.
15. Brandt MR, Kehlet H, Faber O, Binder C. C-peptide and insulin during blockade of the hyperglycemic
response to surgery by epidural analgesia. Clin Endocrinol 1979; 6:167.
16. Clarke RS. The hyperglycaemic response to different types of surgery and anaesthesia. Br J Anaesth
1970; 42:45.
17. Clarke RS, Johnston H, Sheridan B. The influence of anaesthesia and surgery on plasma cortisol,
insulin and free fatty acids. Br J Anaesth 1970; 42:295.
18. Russell RC, Walker CJ, Bloom SR. Hyperglucagonaemia in the surgical patient. Br Med J 1975; 1:10.
19. Arimaa M, Sltis P, Haapaniemi L, Jeglinsky B. Glucose tolerance and insulin response during and
after elective skeletal surgery. Ann Surg 1974; 179:926.
20. Wright PD, Henderson K, Johnston ID. Glucose utilization and insulin secretion during surgery in man.
Br J Surg 1974; 61:5.
21. Lattermann R, Carli F, Wykes L, Schricker T. Perioperative glucose infusion and the catabolic response
to surgery: the effect of epidural block. Anesth Analg 2003; 96:555.
22. Schricker T, Gougeon R, Eberhart L, et al. Type 2 diabetes mellitus and the catabolic response to
surgery. Anesthesiology 2005; 102:320.
23. Gavin LA. Perioperative management of the diabetic patient. Endocrinol Metab Clin North Am 1992;
21:457.
24. Kennedy DJ, Butterworth JF 4th. Clinical review 57: Endocrine function during and after
cardiopulmonary bypass: recent observations. J Clin Endocrinol Metab 1994; 78:997.
25. Clement S, Braithwaite SS, Magee MF, et al. Management of diabetes and hyperglycemia in hospitals.
Diabetes Care 2004; 27:553.
26. King JT Jr, Goulet JL, Perkal MF, Rosenthal RA. Glycemic control and infections in patients with
diabetes undergoing noncardiac surgery. Ann Surg 2011; 253:158.
27. Frisch A, Chandra P, Smiley D, et al. Prevalence and clinical outcome of hyperglycemia in the
perioperative period in noncardiac surgery. Diabetes Care 2010; 33:1783.
28. Buchleitner AM, Martnez-Alonso M, Hernndez M, et al. Perioperative glycaemic control for diabetic
patients undergoing surgery. Cochrane Database Syst Rev 2012; :CD007315.
29. Canadian Diabetes Association Clinical Practice Guidelines, 2013
http://guidelines.diabetes.ca/App_Themes/CDACPG/resources/cpg_2013_full_en.pdf (Accessed on
April 24, 2013).
30. Umpierrez GE, Hellman R, Korytkowski MT, et al. Management of hyperglycemia in hospitalized
patients in non-critical care setting: an endocrine society clinical practice guideline. J Clin Endocrinol
Metab 2012; 97:16.
31. Standards of Medical Care in Diabetes-2016: Summary of Revisions. Diabetes Care 2016; 39 Suppl
1:S4.
32. Joshi GP, Chung F, Vann MA, et al. Society for Ambulatory Anesthesia consensus statement on
perioperative blood glucose management in diabetic patients undergoing ambulatory surgery. Anesth
Analg 2010; 111:1378.
33. Dhatariya K, Levy N, Kilvert A, et al. NHS Diabetes guideline for the perioperative management of the
adult patient with diabetes. Diabet Med 2012; 29:420.
34. Inoue S, Egi M, Kotani J, Morita K. Accuracy of blood-glucose measurements using glucose meters and
arterial blood gas analyzers in critically ill adult patients: systematic review. Crit Care 2013; 17:R48.
35. Hirsch IB, McGill JB. Role of insulin in management of surgical patients with diabetes mellitus. Diabetes
Care 1990; 13:980.
36. Peters A, Kerner W. Perioperative management of the diabetic patient. Exp Clin Endocrinol Diabetes
1995; 103:213.
37. Metchick LN, Petit WA Jr, Inzucchi SE, et al. Inpatient management of diabetes mellitus. Am J Med
2002; 113:317.
38. Marks JB. Perioperative management of diabetes. Am Fam Physician 2003; 67:93.
39. Smiley DD, Umpierrez GE. Perioperative glucose control in the diabetic or nondiabetic patient. South
Med J 2006; 99:580.
40. Hoogwerf BJ. Perioperative management of diabetes mellitus: how should we act on the limited
evidence? Cleve Clin J Med 2006; 73 Suppl 1:S95.
41. Watts NB, Gebhart SS, Clark RV, Phillips LS. Postoperative management of diabetes mellitus: steady-
state glucose control with bedside algorithm for insulin adjustment. Diabetes Care 1987; 10:722.
42. Pezzarossa A, Taddei F, Cimicchi MC, et al. Perioperative management of diabetic subjects.
Subcutaneous versus intravenous insulin administration during glucose-potassium infusion. Diabetes
Care 1988; 11:52.
43. van den Berghe G, Wouters P, Weekers F, et al. Intensive insulin therapy in critically ill patients. N Engl
J Med 2001; 345:1359.
44. Van den Berghe G, Wilmer A, Hermans G, et al. Intensive insulin therapy in the medical ICU. N Engl J
Med 2006; 354:449.
45. Goldberg NJ, Wingert TD, Levin SR, et al. Insulin therapy in the diabetic surgical patient: metabolic and
hormone response to low dose insulin infusion. Diabetes Care 1981; 4:279.
46. Thomas DJ, Platt HS, Alberti KG. Insulin-dependent diabetes during the peri-operative period. An
assessment of continuous glucose-insulin-potassium infusion, and traditional treatment. Anaesthesia
1984; 39:629.
47. Hoogwerf BJ. Perioperative management of diabetes mellitus: striving for metabolic balance. Cleve Clin
J Med 1992; 59:447.
48. Umpierrez GE, Smiley D, Jacobs S, et al. Randomized study of basal-bolus insulin therapy in the
inpatient management of patients with type 2 diabetes undergoing general surgery (RABBIT 2 surgery).
Diabetes Care 2011; 34:256.
49. Cryer PE, Axelrod L, Grossman AB, et al. Evaluation and management of adult hypoglycemic disorders:
an Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab 2009; 94:709.
50. Abdelmalak BB, Bonilla AM, Yang D, et al. The hyperglycemic response to major noncardiac surgery
and the added effect of steroid administration in patients with and without diabetes. Anesth Analg 2013;
116:1116.
51. Morariu AM, Loef BG, Aarts LP, et al. Dexamethasone: benefit and prejudice for patients undergoing
on-pump coronary artery bypass grafting: a study on myocardial, pulmonary, renal, intestinal, and
hepatic injury. Chest 2005; 128:2677.
52. Hirsch IB, Paauw DS. Diabetes management in special situations. Endocrinol Metab Clin North Am
1997; 26:631.
Topic 1753 Version 20.0
GRAPHICS
Pharmacokinetics of the most commonly used insulin preparations
Insulin type Onset of action Peak effect Duration of action
Lispro, aspart, glulisine 5 to 15 minutes 45 to 75 minutes Two to four hours
Regular About 30 minutes Two to four hours Five to eight hours
NPH About two hours 4 to 12 hours 18 to 28 hours
Insulin glargine About two hours No peak 20 to >24 hours
Insulin detemir About two hours Three to nine hours 6 to 24 hours*
NPL About two hours Six hours 15 hours
Insulin degludec About two hours No peak >40 hours
NPH: neutral protamine hagedorn; NPL: neutral protamine lispro.

* Duration of action is dose-dependent. At higher doses (0.8 units/kg), mean duration of action is longer and less
variable (22 to 23 hours).
Graphic 73676 Version 8.0
Sample subcutaneous sliding scale using short-acting insulin
Insulin sensitive Usual Insulin resistant
Glucose values (mg/dL/mmol/L) AC HS AC HS AC HS
<150/8.3 0 0 0 0 0 0
151 to 200/8.4 to 11.1 0 0 2 0 4 2
201 to 250/11.2 to 13.9 2 0 4 0 8 4
251 to 300/13.9 to 16.6 3 1 6 2 12 6
301 to 350/16.7 to 19.4 4 2 8 4 16 8
351 to 400/19.5 to 22.2 5 3 10 6 20 10
AC: before meals; HS: bedtime.
Graphic 83834 Version 1.0
Contributor Disclosures
Nadia A Khan, MD, MSc Nothing to disclose William A Ghali, MD, MPH Nothing to disclose Enrico
Cagliero, MD Nothing to disclose David M Nathan, MD Nothing to disclose Stephanie B Jones,
MD Nothing to disclose Jean E Mulder, MD Nothing to disclose
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are
addressed by vetting through a multi-level review process, and through requirements for references to be
provided to support the content. Appropriately referenced content is required of all authors and must
conform to UpToDate standards of evidence.
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individuals. Key elements of the initial assessment include the following:

Long-term complications of diabetes mellitus, including retinopathy, nephropathy, neuropathy, autonomic

Assessment of hypoglycemia, including frequency, timing, awareness, and severity

EFFECT OF SURGERY ON GLUCOSE CONTROL Surgery and general anesthesia cause a

catabolism, leading to hyperglycemia and even ketosis in some cases [15-24].

GOALS OF GLYCEMIC CONTROL

General goals The goals of perioperative diabetes management include:

Hypoglycemia is a potentially life-threatening complication of poor perioperative metabolic control. Severe

Sulfonylureas increase the risk of hypoglycemia

Type 1 or insulin-treated type 2 diabetes

Omit any short- or rapid-acting insulin on the morning of surgery.

The goals of perioperative diabetic management include avoidance of hypoglycemia, prevention of

Use of UpToDate is subject to the Subscription and License Agreement.

http://www.cdc.gov/diabetes/pubs/pdf/ndfs_2011.pdf (Accessed on June 04, 2012).

Topic 1753 Version 20.0

Pharmacokinetics of the most commonly used insulin preparations

Insulin type Onset of action Peak effect Duration of action

Lispro, aspart, glulisine 5 to 15 minutes 45 to 75 minutes Two to four hours

Regular About 30 minutes Two to four hours Five to eight hours

NPH About two hours 4 to 12 hours 18 to 28 hours

Insulin glargine About two hours No peak 20 to >24 hours

Insulin detemir About two hours Three to nine hours 6 to 24 hours*

NPL About two hours Six hours 15 hours

Insulin degludec About two hours No peak >40 hours

NPH: neutral protamine hagedorn; NPL: neutral protamine lispro.

Graphic 73676 Version 8.0

Sample subcutaneous sliding scale using short-acting insulin

Insulin sensitive Usual Insulin resistant

Glucose values (mg/dL/mmol/L) AC HS AC HS AC HS

151 to 200/8.4 to 11.1 0 0 2 0 4 2

201 to 250/11.2 to 13.9 2 0 4 0 8 4

251 to 300/13.9 to 16.6 3 1 6 2 12 6

301 to 350/16.7 to 19.4 4 2 8 4 16 8

351 to 400/19.5 to 22.2 5 3 10 6 20 10

AC: before meals; HS: bedtime.

Graphic 83834 Version 1.0

Conflict of interest policy

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