Perioperative management of blood glucose

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CHAPTER 226

Perioperative management of blood glucose

Aaron M. Joffe, DO and Douglas B. Coursin, MD

Critical illness, anesthesia, and the metabolic stress of surgery result in neurohormone and metabolic dysregulation, leading to elevated rates of perioperative hyperglycemia. Although perioperative hyperglycemia was once believed to be a normal adaptive response supplying more substrate to stressed organs, it is now clear that outcomes are worse in patients who have hyperglycemia. Unfortunately, a dearth of direct evidence is available to guide anesthesia providers within the operating room as to what is an acceptable blood glucose level and how to achieve that level; most of the current recommendations are based on data extrapolated from studies of patients admitted to general medical or surgical wards or the intensive care unit.

The avoidance of hyperglycemia, hypoglycemia, loss of electrolytes, and loss of free water and the prevention of ketogenesis are the main goals of perioperative glycemic control. To accomplish these goals, consideration should be paid to the type of diabetes mellitus (DM) the patient has, the antecedent pharmacologic therapy of the DM, the degree of metabolic control prior to surgery, and the type and duration of the operation the patient is to undergo. A summary of this approach is presented in Table 226-1.

Table 226-1

Perioperative Management of Patients with Diabetes Mellitus

Surgical Scenario	Fasting BGC	Treatment
Minor operation, patient has type 2 DM, NOT treated with insulin	All patients	Hold oral agents day of operation.
	<180 mg/dL*	Cover with regular or rapid-acting insulin (lispro, aspart, glulisine) as needed.
	>180 mg/dL^†	Plan to initiate a continuous insulin infusion.
	All patients	Target BGC 80-180 mg/dL.
Minor operation, patient has type 1 or type 2 DM, treated with insulin	<180 mg/dL*	Give ½ of intermediate-acting insulin dose morning of operation.
		Consider adding 5% dextrose-containing solution to IV infusion with or without potassium, depending on starting lab values and time of NPO.
		Check serial BGC q4-6 h while patient is NPO and supplement with short-acting insulin.
		Those taking basal insulin, by injection or continuous pump, should receive their usual basal dose or infusion rate.
		Restart preadmission insulin therapy once oral intake tolerated.
	180 mg/dL^†	Start continuous insulin infusion and check BGC q1-2 h.
Major operation, patient has type 1 or type 2 DM treated with insulin	All patients	Hold oral agents day of surgery.
		Start continuous insulin infusion in OR and continue postoperatively.
		Target BGC of 150 mg/dL; avoid hypoglycemia (<80 mg/dL).

BGC, Blood glucose concentration; DM, diabetes mellitus; NPO, nothing by mouth (nil per os); OR, operating room.

^*Fair control.

^†Poor control.

Adapted with permission from Smiley DD, Umpierrez GE. Perioperative glucose control in the diabetic or nondiabetic patient. South Med J. 2006;99:580-589.