Perioperative Diabetes Management

Quick Answer

Diabetes mellitus affects 10-15% of surgical patients, with perioperative hyperglycemia associated with increased morbidity including surgical site infections, delayed wound healing, cardiovascular events, and mortality. The optimal perioperative glucose target is 6-10 mmol/L (110-180 mg/dL)—tighter control (targeting <6 mmol/L) increases hypoglycemia risk without outcome benefit, while values >10 mmol/L are associated with adverse events. Type 1 diabetes patients must NEVER stop basal insulin—even when fasting, to prevent diabetic ketoacidosis (DKA). For elective surgery, HbA1c <8% (64 mmol/mol) is recommended; values >8-9% warrant delay and optimisation unless emergency. Sliding scale insulin alone is NOT recommended—it is reactive and results in wide glucose fluctuations; instead, use basal-bolus insulin protocols or variable-rate intravenous insulin infusion (VRIII) for patients with poor control, type 1 diabetes, or major surgery. Hypoglycemia (<4 mmol/L) is the most feared acute complication—recognise with symptoms, sweating, confusion, or capillary glucose check, and treat immediately with 15-20g fast-acting carbohydrate (e.g., 100-150 mL fruit juice, 3-4 glucose tablets) and recheck in 15 minutes.

Clinical Pearl: The stress response to surgery increases counter-regulatory hormones (cortisol, catecholamines, glucagon), causing hyperglycemia even in non-diabetic patients. Insulin requirements typically increase by 20-40% in the perioperative period for diabetic patients.[1]

Epidemiology and Surgical Impact

Diabetes Prevalence in Surgical Patients

Impact of Hyperglycemia on Surgical Outcomes

Mechanisms: Impaired immune function, collagen synthesis, microvascular dysfunction, oxidative stress, endothelial dysfunction.[8,9,10]

Perioperative Stress Response

Counter-Regulatory Hormone Surge:

• Cortisol ↑ 2-5x baseline
• Catecholamines ↑ 3-10x
• Glucagon ↑ 2-3x
• Growth hormone ↑

Metabolic Effects:

• Increased hepatic glucose production (gluconeogenesis, glycogenolysis)
• Peripheral insulin resistance
• Protein catabolism
• Lipolysis and ketogenesis (in insulin deficiency)

Result: Even non-diabetic patients may develop "stress hyperglycemia" (>7.8-10 mmol/L); diabetic patients experience 20-40% increased insulin requirements.[11,12]

Preoperative Assessment and Optimisation

Preoperative Glycemic Assessment

HbA1c Interpretation:

[13,14,15]

End-Organ Assessment

Cardiovascular (50-80% of diabetic deaths):

• Silent ischaemia common (autonomic neuropathy)
• ECG in all patients >40 years or with symptoms
• Consider stress testing if high-risk surgery + poor functional status
• Optimise blood pressure (<130/80 mmHg if possible)

Renal:

• eGFR assessment (contrast-induced nephropathy risk)
• Avoid nephrotoxic drugs
• Dose-adjust medications

Neurological:

• Autonomic neuropathy (gastroparesis, orthostatic hypotension)
• Peripheral neuropathy (positioning precautions)

Ophthalmological:

• Proliferative retinopathy (avoid Valsalva, extreme hypotension)

Airway:

• Difficult intubation (limited joint mobility, obesity)
• "Prayer sign" (limited metacarpophalangeal joint mobility predictive)

[16,17,18]

Glycemic Targets and Rationale

Recommended Glucose Targets

Rationale:

• Lower limit 4-6 mmol/L: Avoid hypoglycemia (brain glucose dependent)
• Upper limit 10-12 mmol/L: Prevent immune dysfunction, infection risk
• Tight control (<6 mmol/L): Associated with hypoglycemia without mortality benefit (NICE-SUGAR trial showed harm with 4.5-6.0 mmol/L target vs 8-10 mmol/L)

[19,20,21,22]

Perioperative Medication Management

Oral Hypoglycemic Agents

Metformin Lactic Acidosis Risk:

• Rare but serious (mortality 30-50%)
• Risk factors: Renal impairment, sepsis, dehydration, contrast, surgery
• Stop 48 hours prior if eGFR <60 or any risk factor
• Restart only when renal function stable, eating, no infection

SGLT2 Inhibitors and Euglycemic DKA:

• Normal glucose but ketones present
• Starvation, dehydration, surgery precipitate
• Stop 3-4 days before major surgery
• Check ketones if unwell post-op

[23,24,25,26]

Insulin Management

Critical Principle: NEVER stop basal insulin in Type 1 diabetes—even when fasting, basal requirement persists (0.5-1.0 units/hr) to prevent ketogenesis.

Type 1 Diabetes

Minor Surgery (<2 hours, eating post-op):

• Continue basal insulin (glargine/detemir at 80% usual dose morning of surgery)
• Hold bolus insulin until eating
• Variable-rate IV insulin infusion (VRIII) if not eating >4-6 hours

Major Surgery (>2 hours, ICU admission expected, not eating >24 hours):

• VRIII mandatory
• Continue basal at 80% or reduce by 20%
• 5% or 10% dextrose + potassium (VRIII protocols)
• Hourly capillary glucose monitoring

Type 2 Diabetes

Minor Surgery:

• Stop oral agents day of surgery
• If well-controlled (HbA1c <7.5%, fasting <8 mmol/L): May not need insulin
• If poor control: Consider VRIII or basal-bolus

Major Surgery:

• VRIII recommended for:
  • HbA1c >8%
  • Fasting glucose >10 mmol/L
  • Emergency surgery
  • Complex procedure (>4 hours)
  • History of poor control

[27,28,29]

Insulin Dosing Protocols

Variable-Rate Intravenous Insulin Infusion (VRIII)

Standard Protocol (ANZCA/JBDS):

Concomitant Fluids:

• 5% dextrose at 100-125 mL/hr OR
• 10% dextrose at 50-75 mL/hr
• Add KCl 10-20 mmol/L (maintain K⁺ >4.0 mmol/L)

Monitoring:

• Capillary glucose: Hourly (every 30 min if unstable)
• Serum K⁺: Every 4-6 hours
• Anion gap/ketones: If glucose >15 mmol/L or unwell

Weaning:

• Resume subcutaneous insulin when eating
• Give SC insulin with meal; stop VRIII 30-60 minutes after SC bolus given
• Ensure overlap to prevent rebound hyperglycemia

[30,31,32]

Basal-Bolus Insulin (Alternative to VRIII)

Suitable for:

• Type 2 diabetes, well-controlled
• Eating post-op day 1
• Not critically ill

Dosing:

• Basal: Continue glargine/detemir at 80% usual dose (or full dose if HbA1c >8%)
• Bolus: Rapid-acting insulin (aspart, lispro, glulisine) with meals
  • Correction scale based on pre-meal glucose
  • Start with 10% of basal dose as bolus if eating full meals

Correction Scale Example:

[33,34]

Intraoperative Management

Glucose Monitoring

Intraoperative Targets:

• 6-10 mmol/L ideal
• Acceptable: 5-12 mmol/L
• Intervene if <4 or >14 mmol/L

Hypoglycemia Recognition and Management

Definition: <4.0 mmol/L (some guidelines <3.9 mmol/L)

Symptoms:

• Autonomic: Sweating, tremors, tachycardia, anxiety, hunger
• Neuroglycopenic: Confusion, drowsiness, slurred speech, seizures, coma
• Perioperative challenge: Patient anaesthetised—cannot report symptoms!

Unrecognised Hypoglycemia Risk Factors:

• Tight glycemic control (<6 mmol/L target)
• Autonomic neuropathy (reduced warning symptoms)
• Beta-blockers (mask adrenergic symptoms)
• General anaesthesia (masking symptoms)
• Female gender, older age, longer diabetes duration

Treatment Protocol:

Perioperative Specifics:

• If GA ongoing: Stop surgery if possible, treat, resume when stable
• If glucose <3.0: Give IV dextrose even if mild symptoms
• Recheck glucose 15 minutes after treatment
• 15g glucose raises blood glucose ~2-3 mmol/L in average adult

[35,36,37]

Hyperglycemia Management

Intraoperative Hyperglycemia >12 mmol/L:

1. Check ketones if >15 mmol/L or T1DM
2. Increase insulin infusion by 2-4 units/hr
3. Ensure adequate fluid (dehydration worsens hyperglycemia)
4. Consider bicarbonate if pH <7.2 + ketones (DKA)
5. Recheck in 30-60 minutes

DKA Perioperatively:

• Rare but life-threatening
• Glucose usually >13.9 mmol/L, pH <7.3, HCO₃ <18, ketones positive
• Management: ICU admission, fluid resuscitation, VRIII, K⁺ replacement, bicarbonate if pH <6.9
• Do NOT proceed with elective surgery

[38,39,40]

Postoperative Management

Ward Management

Transition from VRIII to Subcutaneous Insulin:

1. Patient eating and drinking normally
2. No infection or steroid use
3. Renal function stable
4. Two stable glucose readings on VRIII

Steps:

1. Give basal insulin (glargine/detemir) with evening meal or morning dose
2. Next meal: Give bolus rapid-acting insulin with food
3. Stop VRIII 30-60 minutes after SC bolus given (prevent hyperglycemia gap)
4. Monitor pre-meal glucose and adjust doses

Sick Day Rules (Patient Unwell Post-Op):

• NEVER stop basal insulin (T1DM)
• Check ketones if glucose >14 mmol/L or unwell
• Increase insulin by 20% if glucose rising + ketones
• Seek medical review if vomiting, persistent hyperglycemia, ketones

[41,42,43]

Special Populations

Steroid-Induced Hyperglycemia

Mechanism: Corticosteroids increase hepatic glucose production, cause peripheral insulin resistance

Management:

• Expect 2-3x increase in insulin requirements
• Use VRIII if high-dose steroids (dexamethasone, methylprednisolone)
• Separate glucose monitoring from steroid dosing (peaks 4-8 hours post-dose)

Enteral/Parenteral Nutrition

Requirements:

• Continuous insulin infusion often needed
• 1 unit per 10-15g carbohydrate (adjust individually)
• Monitor every 4-6 hours

[44,45]

Indigenous Health Considerations

Aboriginal and Torres Strait Islander Peoples

Disproportionate Burden:

Aboriginal Australians experience 3-4 times higher rates of type 2 diabetes compared to non-Indigenous Australians, often with:

• Earlier age of onset (often 30-40 years vs 60+ years)
• Higher complication rates at diagnosis
• Reduced access to specialist diabetes care
• Geographic barriers to preoperative optimisation

Remote Practice Considerations:

Clinical Recommendations:

1. Preoperative assessment:

   • Assume higher complication risk
   • Comprehensive end-organ screening
   • ECG even if younger (high cardiovascular risk)
   • Foot examination (peripheral neuropathy, ulcers)

2. Perioperative management:

   • Low threshold for VRIII (higher complication risk)
   • Meticulous glucose monitoring
   • Involve Aboriginal Health Workers in education
   • Clear discharge planning with ACCHO follow-up

3. Cultural safety:

   • Explain procedures with visual aids
   • Address fears about insulin therapy
   • Family involvement in care decisions
   • Non-judgmental approach to control issues

[46,47,48,49]

Māori Health Considerations

Diabetes Disparities:

Māori experience significant disparities in diabetes:

• 2-3 times higher prevalence than non-Māori
• Higher hospitalisation rates for complications
• Younger age at diagnosis
• Socioeconomic barriers to optimal control

Whānau-Centred Approach:

When managing perioperative diabetes in Māori patients:

1. Preoperative optimisation:

   • Early identification of HbA1c >8%
   • Endocrinology referral if poorly controlled
   • Coordinate with Māori Health Services

2. Communication:

   • Explain diabetes management in accessible language
   • Whānau involvement in medication adherence
   • Cultural advisors for complex decisions

3. Postoperative care:

   • Whānau support for insulin administration
   • Address barriers to follow-up (transport, cost)
   • Coordinate discharge with community diabetes services

Equity Considerations:

• Ensure equivalent access to insulin pumps, continuous glucose monitoring
• Address structural determinants of poor control
• Provide culturally safe education resources

[50,51,52,53]

ANZCA Final Exam Focus

Key Viva Questions

Q: "Why is tight glycemic control (targeting 4-6 mmol/L) not recommended in the perioperative period?"

Model Answer: "Tight glycemic control targeting 4 to 6 millimoles per litre is not recommended because it significantly increases the risk of hypoglycemia without providing mortality benefit. The seminal NICE-SUGAR trial demonstrated that intensive glucose control targeting 4.5 to 6.0 millimoles per litre in critically ill patients actually increased mortality compared to a more moderate target of 8 to 10 millimoles per litre. The increased mortality was primarily attributed to hypoglycemia, which is particularly dangerous in the perioperative period because it can cause seizures, brain injury, cardiac arrhythmias, and is often asymptomatic in anaesthetised patients.

Furthermore, the stress response to surgery increases counter-regulatory hormones, causing insulin resistance and unpredictable glucose fluctuations. Attempting tight control in this setting requires high insulin doses that predispose to hypoglycemia when the stress response subsides or nutrition is interrupted. The current consensus targets 6 to 10 millimoles per litre as this range minimises hypoglycemia risk while preventing the immune dysfunction, impaired wound healing, and infection risk associated with hyperglycemia above 10 to 12 millimoles per litre."

Q: "A patient with type 1 diabetes is fasting for elective surgery scheduled for tomorrow morning. How would you manage their insulin?"

Model Answer: "For a type 1 diabetic patient fasting for surgery, the most critical principle is to never stop their basal insulin, even when fasting. Basal insulin is essential to prevent lipolysis and ketogenesis, which can lead to diabetic ketoacidosis within hours to days even without hyperglycemia.

My approach would be to reduce the patient's long-acting basal insulin, such as glargine or detemir, to eighty percent of their usual dose the night before or morning of surgery. This reduction accounts for the reduced carbohydrate intake while maintaining essential basal coverage. I would hold all bolus or prandial insulin since the patient is not eating.

For minor surgery less than two hours where they will eat afterward, this approach may suffice with capillary glucose monitoring every two to four hours. However, for major surgery, prolonged fasting, or if their control is poor, I would initiate a variable rate intravenous insulin infusion using a standard protocol with 5 or 10 percent dextrose and potassium supplementation. This provides tight glycemic control while maintaining substrate delivery to prevent ketosis. Throughout the fasting period, I would monitor glucose hourly, watching for hypoglycemia, and I would have intravenous dextrose immediately available for emergency treatment."

Q: "What is euglycemic diabetic ketoacidosis, and which perioperative medications increase this risk?"

Model Answer: "Euglycemic diabetic ketoacidosis is a potentially life-threatening condition where patients develop significant ketonemia and metabolic acidosis despite blood glucose levels that are only mildly elevated or even normal, typically under 11.1 millimoles per litre. This contrasts with typical diabetic ketoacidosis where glucose is markedly elevated, usually above 13.9 millimoles per litre.

The pathophysiology involves insulin deficiency combined with starvation and dehydration, leading to lipolysis and ketone production without severe hyperglycemia. Perioperatively, the main medications that increase this risk are the sodium-glucose cotransporter 2 inhibitors, or SGLT2 inhibitors, including dapagliflozin, empagliflozin, and canagliflozin. These drugs promote glucosuria, which lowers blood glucose, but they also stimulate lipolysis and ketogenesis through multiple mechanisms including increased glucagon levels. When combined with the starvation state of surgery, reduced carbohydrate intake, and the stress response, they significantly predispose to euglycemic ketoacidosis. For this reason, current guidelines recommend stopping SGLT2 inhibitors three to four days before major surgery and checking ketones if the patient becomes unwell postoperatively, even if glucose is not markedly elevated."

SAQ Practice Question

Question (20 marks): A 58-year-old man with type 2 diabetes (HbA1c 8.2%, metformin 1g BD, gliclazide 80 mg BD) is scheduled for laparoscopic cholecystectomy. He is fasting from midnight. His morning capillary glucose is 12.5 mmol/L.

a) How would you manage his oral hypoglycemic medications perioperatively? (6 marks) b) Describe your intraoperative glycemic management strategy (8 marks) c) When and how would you transition back to his usual oral medications postoperatively? (6 marks)

Model Answer:

a) Perioperative medication management (6 marks):

Metformin:

• Stop 48 hours before surgery if eGFR <60 or contrast planned, OR stop morning of surgery if normal renal function
• Rationale: Risk of lactic acidosis with hypoperfusion, sepsis, contrast
• Restart when: Eating normally, renal function stable, no tissue hypoperfusion

Gliclazide (sulfonylurea):

• Stop morning of surgery (day of procedure)
• Rationale: Risk of hypoglycemia when fasting; long duration of action
• Restart when: Eating normally, glucose stable

Preoperative glucose management:

• Morning glucose 12.5 mmol/L indicates suboptimal control
• For moderate surgery with glucose >10 mmol/L, consider VRIII OR variable-rate insulin infusion
• Alternatively, if minor surgery and short duration: Monitor closely, treat if >14 mmol/L intraoperatively
• Decision: Start VRIII (preferred given HbA1c 8.2% + morning hyperglycemia)

Preoperative optimisation issues:

• HbA1c 8.2% above target (<8% for elective)
• But not severe enough to postpone cholecystectomy unless high cardiac risk
• Ensure end-organ assessment completed (cardiac, renal)

b) Intraoperative glycemic management (8 marks):

Monitoring:

1. Capillary glucose: Hourly intraoperatively
2. Targets: 6-10 mmol/L (acceptable 5-12 mmol/L)
3. Intervention thresholds: <4 or >14 mmol/L

Insulin protocol (VRIII): 4. Variable-rate intravenous insulin infusion based on capillary glucose:

5. Concomitant fluids:
   • 5% dextrose at 100-125 mL/hr OR 10% dextrose at 50 mL/hr
   • Add potassium chloride 10-20 mmol/L (maintain K⁺ >4.0)
   • Continue maintenance fluids if NBM extended

Laparoscopic considerations: 6. Insulin requirements may increase with pneumoperitoneum (stress response, catecholamines) 7. Watch for hyperglycemia when CO₂ insufflation starts 8. Ensure glucose checked after position changes (often head-up)

Hypoglycemia preparation: 9. 20% glucose or 50% glucose immediately available 10. Treatment protocol if <4 mmol/L:

• STOP insulin
• Give 100-150 mL 10% glucose OR 75-100 mL 20% glucose IV
• Recheck in 15 minutes
• Resume insulin when glucose >6 mmol/L

Anaesthetic technique: 11. Avoid long-acting opioids (respiratory depression with glucose fluctuations) 12. Adequate analgesia reduces stress response 13. PONV prophylaxis (metoclopramide, dexamethasone—note: steroids raise glucose)

c) Transition to oral medications (6 marks):

Criteria for transition:

1. Patient eating and drinking normally (at least 50% usual intake)
2. No nausea/vomiting
3. Pain controlled with oral analgesia
4. No infection or sepsis
5. Two stable capillary glucose readings on current insulin regimen

Transition steps: 6. Give fasting acting insulin (e.g., aspart, lispro) with first meal

• Dose: 6-8 units with meal (conservative, can increase)
• OR if previously on insulin: 50% of home basal dose as bolus

7. Stop VRIII 30-60 minutes after subcutaneous insulin given

   • Prevents rebound hyperglycemia from insulin gap
   • SC insulin needs time to absorb

8. Restart oral medications when eating normally:

   • Metformin: Restart when eating, renal function stable (check eGFR post-op, contrast given)
   • Gliclazide: Restart with meals; morning dose if eating breakfast
   • Consider reducing gliclazide initially (hypoglycemia risk post-op with reduced intake)

Postoperative day 1-2 monitoring: 9. Capillary glucose: Before meals and at bedtime 10. Targets: 6-10 mmol/L pre-meal, <12 mmol/L post-meal 11. Adjust insulin/oral doses based on readings

Discharge planning: 12. Ensure patient has glucose meter and supplies 13. Written instructions on sick day rules 14. Follow-up with GP/diabetes nurse within 1 week 15. HbA1c recheck in 3 months (target <7-7.5% if safely achievable)

Steroid consideration: 16. If dexamethasone given for PONV: May need increased gliclazide or temporary insulin for 24-48 hours

Summary and Key Takeaways

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