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their habits of critical inquiry and balanced judgement, and to contribute to better patient care. Disclosures: Susan E. Spratt, MD, current author of this module, is a consultant and speaker for Sanofi Aventis and Novo Nordisk. Deborah Korenstein, MD, FACP, Co-Editor, PIER, has no financial

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Perioperative Management of Diabetes

Mellitus View online at http://pier.acponline.org/physicians/diseases/periopr879/periopr879.html

Module Updated: 2012-10-01

CME Expiration: 2015-10-01

Author

Susan E. Spratt, MD

Table of Contents

1. Elements of Risk.................................................................................................................2

2. Whom and How to Assess ....................................................................................................5

3. Interventions to Decrease Risk .............................................................................................13

4. Patient Counseling ..............................................................................................................24

5. Follow-up ..........................................................................................................................27

References ............................................................................................................................29

Glossary................................................................................................................................33

Tables ...................................................................................................................................35

Figures .................................................................................................................................44

http://pier.acponline.org/physicians/diseases/periopr879/periopr879.html

Perioperative Management of Diabetes Mellitus


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1. Elements of Risk Top

Recognize that diabetes mellitus is a major risk factor for serious perioperative complications.

1.1 Appreciate that patients with diabetes are at increased risk for perioperative complications and morbidity, including cardiovascular and

infectious complications and DKA.

Recommendations

• Be aware that patients with diabetes are at risk for developing perioperative complications that are

associated with high rates of morbidity and mortality, including:

Hyperglycemia

Hypoglycemia

DKA

Postoperative infections such as wound and urinary tract infections

Cardiac complications such as MI and death (see module Preoperative Cardiac Risk Assessment)

Postoperative stroke

Evidence

• In a prospective cohort study of 520 patients undergoing elective surgery (general, vascular,

thoracic, and head and neck surgery), abnormal glucose levels were found in 69% of patients with

diabetes compared to 13% in those without diabetes (P<0.0001) (1).

• A therapeutic trial showed that higher glucose levels postoperatively were associated with an

increased rate of infection and mortality (2).

• A 2003 American Diabetes Association review stated that the mortality rate associated with DKA is

<5% in younger individuals, and 15% for patients with hyperosmolar nonketoacidosis (3).

• In a retrospective chart review of 338 patients with a discharge diagnosis of DKA, the mortality

rate for older individuals (>65 years) was 22% (4).

• In a randomized, controlled trial of 1548 patients assigned to either intensive or conventional

insulin therapy in the postoperative period, the rate of hypoglycemic episodes (defined as <40

mg/dL or <2.2 mmol/L) among the intensive insulin treatment group was 5% (39 out of 765). Only

2 patients developed symptoms of agitation and diaphoresis, but no patient suffered from seizures

or coma (2).

• In an observational study of 2402 CABG surgeries done between 1977 and 1991, there were 125

episodes of wound infection (5%). Only steroid use and diabetes were identified as predictor

variables for postoperative wound infections (5).

• In a prospective cohort of 561 patients undergoing lower extremity vascular surgery, 4% of

patients developed postoperative surgical wound infections. The presence of diabetes was

associated with development of wound infections (6).

• In a case-controlled study of patients with deep sternal site infection after CABG, several variables

were identified as predicting wound infections, including diabetes with preoperative glucose >110

mg/dL (OR, 3.7) and 125 mg/dL (OR, 10.2) (7).

• In a retrospective cohort study of 254 consecutive patients referred for nuclear cardiology testing

before vascular surgery, investigators found that if one or two clinical predictors (ventricular

ectopy, Q waves on ECG, advanced age, diabetes, or angina) were present, there was a 15.5%

chance of having early postoperative ischemic events (CI, 7% to 21%). For patients with none of

http://pier.acponline.org/physicians/diseases/preopr157/preopr157.html



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these risk factors, there was a low risk for cardiovascular events or death. If a patient had three or

more risk factors, the risk for cardiovascular events was high (50%). This risk estimate for the

intermediate group was further refined using thallium scintigraphy (8).

• In a validated prospective cohort study of 1081 patients undergoing vascular surgery, history of MI

(abnormal Q waves or by history), angina, aged >70 years, diabetes, history of HF, or previous

coronary revascularization in combination with an abnormal dipyridamole thallium scintography

result predicted postoperative cardiac events (9).

• From a validated prospective cohort study of 4315 patients undergoing elective noncardiac surgery,

investigators determined a six-variable, equally weighted scoring system that was more accurate in

predicting major cardiac events in patients aged ≥50 years hospitalized for at least 2 days. The six

variables included preoperative use of insulin, history of HF, history of ischemic heart disease,

history of cerebrovascular disease, significant renal impairment (creatinine level >2.0 mg/dL or

177 mmol/L), and major surgery. Each of these variables was associated with an adjusted OR

between 1.9 and 3.0 for major cardiac events (10).

• In a prospective cohort study (1996 to 2001), 16,184 patients undergoing cardiac surgery were

monitored for development of postoperative stroke. Stroke occurred in 4.6% of patients and was

independently associated with history of diabetes in multivariable analysis (11).

• In a retrospective analysis of patients undergoing cardiac surgery, diabetes was associated with

major complications such as bacterial endocarditis and sternal osteomyelitis (12).

• In a prospective study of 5031 patients undergoing noncardiac surgery (1995 to 2000), 3.2%

developed surgical site infections. Diabetes was an independent risk factor for development of the

surgical site infection by multivariable analysis (13).

• In a retrospective study of 197,461 patients who underwent lumbar fusion (1998 to 2003), the

11,000 patients with diabetes (5.6% of the cohort) had an increased risk of postoperative infection,

need for transfusion, pneumonia, and longer duration of hospital stay (14).

• A prospective trial of patients undergoing carotid endarterectomy showed a higher rate of stroke

and death within 30 days of surgery in patients with diabetes (4.5% vs. 1.5% in patients without

diabetes (15).

• An observational study of 3184 noncardiac surgery patients reported that perioperative

hyperglycemia is correlated with increased length of ICU and hospital stay, complications, and

mortality after noncardiac surgery. Hospital complications more common in patients with

hyperglycemia included sepsis, renal failure, UTI, and MI (16).

• A prospective, observational study of 5050 patients undergoing CABG noted that mortality was

higher in patients with diabetes and in patients without diabetes who have postoperative

hyperglycemia (17).

Rationale

• Patients with diabetes are more likely to have high glucose levels than those without diabetes.

• Elevated glucose levels are associated with higher risk for postoperative infections and death.

• Patients with type 1 diabetes require insulin (± glucose) even when glucose levels are in the

normal range. Inadequate insulin therapy can result in serious complications, such as DKA.

• Hypoglycemia can be caused by overly aggressive glucose reduction therapy, insufficient glucose

intake, or increased glucose use perioperatively and can lead to seizures, coma, and death.

• Unrecognized hypoglycemia can cause severe neurologic sequelae.

• Rates of postoperative wound infections are much higher in patients with diabetes than in those

without.



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• Patients with diabetes are at higher risk for perioperative HF, MI, stroke, and cardiac death than

those without diabetes.

Comments

• The CDC estimates that 25.8 million people (11.3% of Americans aged over 20 years) have

diabetes; 7 million remain undiagnosed.

• The Canadian Heart Health Survey (1986 to 1992) found that 5% of Canadians have diabetes (19).

In a cohort of patients with diabetes, approximately 50% required surgery during their lifetime

(20).



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2. Whom and How to Assess Top

Assess all patients with diabetes before surgery with careful history, physical exam, lab testing, and additional cardiac testing in selected patients.

2.1 Identify patients who may be at risk for developing DKA as part of the

routine preoperative evaluation.

Recommendations

• Identify patients with type 1 diabetes and insulin-deficient type 2 diabetes.

• Recognize that all patients with type 1 diabetes are at risk for developing postoperative DKA.

• In patients with type 1 diabetes, look for DKA by testing serum ketones, bicarbonate level, and

anion gap, and if these tests are abnormal, postpone surgery and treat with insulin and fluids.

• Consider patients with type 2 diabetes and any of the following characteristics to be prone to DKA:

Young age (aged <40 years)

Use of insulin alone to control hyperglycemia

BMI <25 kg/m2

History of DKA

Family history of type 1 diabetes

History of pancreatectomy or pancreatic dysfunction

• Recognize that stress and infection can precipitate hyperglycemia.

• Recognize that the administration of pharmacologic agents such as vasopressors or glucocorticoids

can cause iatrogenic hyperglycemia.

• Recognize that withholding insulin can cause hyperglycemia and DKA.

• Recognize that pancreatic surgery can increase the risk of derangement of glycemic control in all

patients, regardless of whether a diagnosis of diabetes has been made.

Evidence

• Mainly consensus.

Rationale

• All patients with type 1 diabetes are at risk for developing DKA.

• DKA can occur in patients with type 2 diabetes, but is relatively uncommon.

• Proper identification of patients who may be prone to DKA will alter postoperative management and

lab testing.

• Patients with type 1 diabetes and insulin-deficient type 2 diabetes are prone to developing DKA,

especially if their insulin is withheld for a prolonged period (even as short as 8 hours).

Comments

• Withholding basal insulin in patients with type 1 diabetes or insulin-deficient type 2 diabetes can

cause hyperglycemia, DKA, and death.

• Preoperative recognition of which patients require basal insulin can prevent hyperglycemia and DKA

and thus, reduce the length of hospital stay and complications.



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• The 2005 to 2008 National Health and Nutrition Examination Survey documented that 13.7% of

people aged between 45 and 64 years and 26.9% of people aged over 64 years with diabetes do

not know that they have diabetes.

2.2 Assess for patient-related risk for hypoglycemia.

Recommendations

• Ask about:

Previous episodes of glucose readings <70 mg/dL (4.0 mmol/L)

Symptoms of lightheadedness, diaphoresis, and nausea that are ameliorated with eating

• Determine the frequency, severity, and awareness of the hypoglycemic episodes, including:

Loss of consciousness, which denotes severe hypoglycemia

Patient awareness of minor symptoms, such as agitation, fatigue, lightheadedness, and feeling cold

• Determine the factors that may explain the episodes of hypoglycemia, such as:

Low intake of calories at specific times

Excessive exercise

Excessive use of insulin or sulfonylureas corresponding to times of hypoglycemia

• Determine if the patient's home dose of insulin is accurate:

Ascertain how the patient takes insulin at home; inquire if the glucose level is normal or low if insulin is not given

Ascertain whether the patient experiences hypoglycemia if a meal is skipped

Evidence

• A related prospective cohort study of outpatients showed that low self-monitored blood glucose

levels predicted severe episodes of hypoglycemia (stupor or unconsciousness) among patients with

type 1 diabetes (21).

• Errors in administration of insulin account for 13% of medication errors in the U.S. (22; 23).

Rationale

• The patient's baseline glycemic control may predict postoperative control and potential risk for

hypoglycemia.

• Identifying factors that may be associated with hypoglycemia will allow the physician to correct an

underlying problem in diabetes management and thereby reduce the risk for postoperative

hypoglycemia when outpatient drug therapy is resumed.

• If the patient skips insulin if the blood glucose level is low, or if the patient has hypoglycemia if a

meal is skipped, then it is likely that the home insulin dose is too high.

• Identifying an accurate insulin dose for each patient reduces hypoglycemia and hyperglycemia

during hospitalization.

2.3 Screen nondiabetic patients undergoing cardiac surgery with preoperative HbA1c.

Recommendations

• Check HbA1c in all patients undergoing cardiac surgery, even if diabetes has not been diagnosed.

• Consider checking HbA1c in all patients undergoing major noncardiac surgery, or confirm that

fasting glucose is under 100 mg/dL in all patients with no diabetes diagnosis undergoing major

surgery. If glucose is over 100 mg/dL, check HbA1c to assess for overall glucose control.

Evidence



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• An observational study of 7310 patients undergoing cardiac surgery found that 5.2% had

undiagnosed diabetes. Patients with undiagnosed diabetes had higher rates of complications and

death than either patients with known diabetes or nondiabetics (24).

• According to the Third National Health and Nutrition Examination Survey (1988 to 1994), 50% of

patients with diabetes are not aware of their diagnosis (18).

• An observational study of 3184 noncardiac surgery patients assessed that perioperative

hyperglycemia is correlated with increased length of ICU and hospital stay, complications, and

mortality after noncardiac surgery. Hospital complications more common in patients with

hyperglycemia included sepsis, renal failure, UTI, and MI (16).

• Patients with diabetes are at increased risk for postoperative surgical site infection (25).

• A prospective, observational study of 5050 patients undergoing CABG noted that mortality was

higher in patients with diabetes and in patients without diabetes who have postoperative

hyperglycemia (17).

Rationale

• Diabetes increases the risk for postoperative wound infection, hospital complications, and

mortality. Twenty-six million Americans have diabetes and one-third are unaware that they have it.

Given the high prevalence of diabetes and increased risk for postoperative complications, it is

important to properly diagnose and treat patients who have diabetes and are undergoing surgery.

2.4 Assess overall health status of patients with diabetes when determining

the patient-related risk for perioperative cardiac complications.

Recommendations

• Determine the level of risk for having a perioperative cardiac complication using the Revised

Cardiac Risk Index and the ACCF/AHA guidelines for perioperative cardiovascular evaluation for

noncardiac surgery.

• Consider whether the patient requires further noninvasive cardiac testing as part of the

preoperative evaluation.

• See module Preoperative Evaluation.

• See module Preoperative Cardiac Risk Assessment.

Evidence

• In a retrospective cohort study of 254 consecutive patients referred for nuclear cardiology before

vascular surgery, investigators found that if one or two clinical predictors (ventricular ectopy, Q

waves on ECG, advanced age, diabetes, or angina) were present, patients had a 15.5% chance of

having early postoperative ischemic events (CI, 7% to 21%). This risk estimate was further refined

using thallium scintography (8).

• In a validated prospective cohort study of 1081 patients undergoing vascular surgery, history of MI

(abnormal Q waves on ECG or by history), angina, age >70, diabetes, history of HF, or previous

coronary revascularization in combination with an abnormal dipyridamole thallium scintigraphic test

result predicted increased postoperative cardiac events (9).

• From a validated prospective cohort study of 4315 patients undergoing elective noncardiac surgery,

investigators determined a six-variable, equally weighted scoring system for cardiac risk

stratification. This Revised Cardiac Risk Index was more accurate in predicting major cardiac

events in patients ≥50 years admitted to hospital for at least 2 days as compared to the Goldman,

Detsky, and American Society of Anesthesiologist risk indices (10).

• The ACCF/AHA guidelines recommend standard risk assessment before surgery (26).

http://www.surgicalcriticalcare.net/Resources/revised_cardiac_risk_index.pdf


http://content.onlinejacc.org/article.aspx?articleid=1140211







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• In a prospective study of 1351 patients undergoing vascular surgery, dobutamine stress ECG was

helpful to further risk stratify patients who were not able to take perioperative β-blockers (27).

• In a prospective cohort study of patients referred for exercise or dobutamine stress ECG, 236

patients with negative results were followed for 25 ± 7 months. There was no difference found in

cardiac death rates among those with and without diabetes (4.2% vs. 5.6%); however, nonfatal MI

was higher in the group with negative test results and diabetes compared with those with negative

test results without diabetes (6.7% vs. 1.4%, P<0.05) (28).

Rationale

• Patients with diabetes are at significant risk of having CAD and postoperative cardiac complications.

• The Revised Cardiac Risk Index is a validated risk scoring system for low-risk individuals

undergoing elective surgery who are aged >50 years and intended to stay in the hospital for at

least 2 days.

• The ACCF/AHA guidelines for perioperative cardiovascular evaluation for noncardiac surgery

provide algorithms for risk stratification that incorporate history, physical exam, lab tests, and

further cardiac testing for all patients undergoing emergent and elective noncardiac surgery.

Comments

• The Revised Cardiac Risk Index was derived from a cohort of mostly lower-risk individuals

undergoing elective surgery and therefore may not be generalized to emergency surgery patients.

2.5 Determine the type of surgical procedure and planned anesthesia

technique.

Recommendations

• Assess whether the patient will undergo minor or major surgery to determine the desired target

glucose range and the strategy to control hyperglycemia:

A minor surgical procedure is of short duration with minimal fluid shifts or tissue dissection

Major surgery is a procedure that is long and complex, such as:

o Intra-abdominal or intrathoracic procedures

o Cardiac surgery

o Major vascular surgery

o Multiple trauma surgery

o Prolonged neurosurgery (>4 hours)

o Transplantation surgery

• Determine if the patient will be undergoing epidural anesthesia or general anesthesia.


Evidence

• In a prospective cohort study, 150 patients undergoing either anesthesia without surgery, surface

surgery, thoracic surgery, or intra-abdominal surgery had serial blood glucose levels measured.

The largest rises in blood glucose were found in the patients undergoing intra-abdominal

procedures followed by thoracic procedures. Body surface surgery and anesthesia without surgery

had the smallest changes in glucose levels (29).

• In a similar prospective cohort study of 36 patients (6 of whom had diabetes), no difference existed

in the degree of hyperglycemia across the different types of surgery among those with and without

diabetes (30).

• A group of 40 elderly patients (20 had type 2 diabetes) scheduled to undergo elective cataract

surgery were randomly allocated to receive standard general anesthetic or local anesthetic. Serial

levels of glucose and cortisol increased in general anesthetic patients (those with diabetes and







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those without) throughout surgery compared with preoperative levels but returned to normal within

4 hours postprocedure. In the local anesthesia group, the serum glucose and cortisol did not

change significantly (31). Although these investigators did not find a difference in the degree of

glucose abnormality in patients with or without diabetes, the sample sizes may have been too

small to detect a difference.

• Physiologic studies have shown that epidural anesthesia has less impact on glucoregulatory

hormones compared to general anesthesia (32).

Rationale

• Studies have found that the magnitude of surgery affects the extent of hyperglycemia.

• Minor surgeries such as dilatation and curettage, mastectomy, and hernia repair cause minimal

changes in glucose levels compared to intra-abdominal or thoracic procedures; major surgeries

that are long and complex require insulin infusions to maintain meticulous control of glucose levels.

• Epidural anesthesia may be less likely to cause stress hyperglycemia.

• Specific types of surgery are associated with certain types of wound infections among patients with

diabetes; open-heart surgery portends a higher risk for developing bacterial endocarditis or sternal

osteomyelitis in patients with diabetes.

Comments

• Patients who undergo intra-abdominal surgery, cardiac surgery, intrathoracic surgery, vascular

surgery, transplant surgery, prolonged neurosurgery, and multiple trauma surgery are at increased

risk for hyperglycemia and infections. These patients often will require close glucose monitoring

and possibly iv insulin perioperatively to maintain tight glycemic control (29).

2.6 Assess preoperative glucose levels in all patients with diabetes to stratify

their risk for postoperative wound infections and in order to optimize preoperative therapy.

Recommendations

• Obtain serum glucose levels (pre-meal or fasting) at the time of the preoperative assessment for

the purposes of risk stratification for postoperative wound infections and to determine if additional

medical therapy may be needed upon discharge.

• Consider postponing elective surgery if glucose levels are high (>220 mg/dL or >12 mmol/L) or if

patients have signs or symptoms of dehydration due to hyperglycemia until glucose levels are

normalized and symptoms have resolved.

• See figure HbA1c Guidance.

Evidence

• In patients with diabetes undergoing abdominal or cardiac surgery, preoperative glucose level

>220 mg/dL increased the risk of nosocomial infection 2.7-fold over those patients with diabetes

whose blood glucose level never increased above 220 mg/dL (33).

• In a case-control study of patients with deep sternal site infection after CABG, variables were

identified as predicting wound infections. Diabetes with a preoperative glucose level >110 mg/dL

increased the risk for mediastinitis three-fold, and diabetes with a preoperative glucose level >125

mg/dL increased the risk 10-fold (7).


thoracic, and head and neck surgery), laboratory and historical features were assessed. In patients

with diabetes, abnormal glucose levels were found in 69% compared to 13% in those without

diabetes (P<0.0001) (1).



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• A systematic review of 16 case series of healthy preoperative patients found that serum glucose

was abnormal in up to 5% of patients and rarely led to changes in clinical management (34).

• Patients with a preoperative blood glucose level >150 mg/dL undergoing knee or hip surgery had a

10% risk of pulmonary embolism (35).

Rationale

• Preoperative hyperglycemia increases the risk for postoperative wound infections.

• Patients with diabetes are more likely to have abnormal preoperative glucose readings compared to

those without diabetes.

• Assess an elevated glucose level at the time of the preoperative assessment in the context of the

patient's dietary intake at that time and their overall glucose control (fasting blood glucose levels

over the past 2 weeks).

• A significantly elevated glucose level (>220 mg/dL or >12 mmol/L) may reflect extremely poor

control of diabetes or an acute process.

Comments

• Although the correlation between hyperglycemia and poor outcomes in surgical patients (especially

postoperative infection) is well documented, there have been no published interventional studies of

obtaining preoperative glycemic control in regard to outcomes.

• Point-of-care glucose testing (also known as bedside glucose monitoring) is preferred for hospital

management of patients with diabetes.

• In all patients with diabetes undergoing purely elective surgery, it seems prudent to obtain blood

glucose levels commensurate with outpatient goals (fasting glucose <120 mg/dL and 2-hour

postprandial glucose <140 mg/dL).

• To achieve glycemic goals, it may be necessary to intensify the medical regimen, including adding

outpatient preoperative insulin.

• In patients undergoing emergency surgery, there is no luxury to obtain tight preoperative glycemic

control, but control can be achieved perioperatively with iv insulin.

2.7 Determine renal function in all patients with diabetes before surgery.

Recommendations

• Obtain preoperative serum creatinine level and possibly BUN levels for all patients with diabetes.

Evidence

• In a prospective cohort study of 4315 patients undergoing elective noncardiac surgery, renal

dysfunction (creatinine level >2.0 mg/dL or 177 mmol/L) was found to be an independent risk

factor for postoperative major cardiac complications both in univariate and multivariate analysis

(OR, 5.2 [CI, 2.6 to 10.3]) (10).

• In a prospective cohort of 520 patients undergoing elective surgery (general, vascular, thoracic,

and head and neck surgery), laboratory and historical features were assessed. In patients with

diabetes, abnormal BUN/creatinine levels were found in 38% compared to 19% in those without

diabetes (P<0.0003) (1).

• In a study of patients undergoing elective surgery, renal function was found to be more likely

abnormal in patients with diabetes in than those without (1); however, in a systematic review of 16

case series of healthy patients, routine testing found that BUN and creatinine levels were abnormal

in up to 2.5% of patients but rarely led to changes in perioperative care (34).



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• In an observational study of 596 critically ill patients, hypoglycemia occurred in 21%.

Hypoglycemia was associated with mortality, respiratory failure, and hemodynamic instability. In

addition to diabetes, chronic renal failure was associated with hypoglycemia (36).

Rationale

• Patients with type 1 and type 2 diabetes often have coexisting renal dysfunction.

• The presence of renal disease significantly increases the risk of postoperative cardiac

complications.

• Renal dysfunction can affect fluid and electrolyte balance, drug dosing, and postoperative

monitoring, as well as affect the safety of radiological and interventional studies with contrast.

2.8 Obtain preoperative urinalysis only in selected situations for diabetic patients; do not obtain routine preoperative urinalysis.

Recommendations

• Do not obtain a urinalysis to screen for urinary tract infection in asymptomatic patients with

diabetes as part of a routine preoperative screening for most surgical procedures.

• Obtain routine preoperative urinalysis screening in all patients undergoing urologic and perhaps

orthopedic procedures.

• Obtain a urinalysis in patients with symptoms of urinary tract infection.

Evidence



with diabetes, abnormal urinalysis was found in 24% compared to 14% in those without diabetes

(P=0.03) (1).

• A systematic review of 16 case series of healthy preoperative patients found that urinalysis was

abnormal in 1% to 34% of patients but led to changes in clinical management in only 1% to 2.8%

(34).

• In a cost analysis, the cost of routine preoperative urinalysis in patients heading for orthopedic

surgery is 500 times greater than the cost of treating additional cases of postoperative wound

infections (37).

• In urologic and orthopedic surgery, urinary tract infections may increase the risk of perioperative

infections (38; 39).

Rationale

• Asymptomatic pyuria (abnormally increased number of leukocytes in the urine) rarely leads to

changes in perioperative management.

• The evidence that pyuria leads to an increased rate of postoperative wound infection among

orthopedic patients is controversial.

• The costs of preoperative screening for UTI would far outweigh the costs of treating additional

cases of postoperative wound infection.

2.9 Obtain a preoperative ECG to further stratify cardiac risk.

Recommendations

• Screen all patients who have diabetes with a resting 12-lead ECG, specifically looking for:

Abnormal Q waves suggesting old MI

Cardiac rhythm other than sinus

Ventricular or atrial ectopy



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• See module Preoperative Cardiac Risk Assessment.

Evidence

• In a retrospective cohort study of 254 consecutive patients referred for nuclear cardiology before

vascular surgery, investigators found that if one or two clinical predictors existed (ventricular

ectopy, Q waves on ECG, advanced age, diabetes, or angina), the patient had a 15.5% chance of

having early postoperative ischemic events (CI, 7% to 21%). This risk estimate was further refined

using thallium scintography (8).

• In the Eagle criteria for vascular surgery, diabetes and an abnormal ECG predicted risk of

postoperative cardiac complications. In a validated prospective cohort study of 1081 patients

undergoing vascular surgery, history of MI (abnormal Q waves on ECG or by history), angina, age

>70, diabetes, history of HF, or previous coronary revascularization in combination with an

abnormal dipyridamole thallium scintigraphic test result predicted increased postoperative cardiac

events (9).

• In a validated prospective study of 4315 patients undergoing noncardiac surgery, the investigators

found that history of ischemic heart disease defined as abnormal Q waves on ECG or by history was

predictive of postoperative cardiac events (10).



with diabetes, abnormal ECG was found in 77% compared to 47% in those without diabetes

(P<0.0001) (1).

• A Revised Cardiac Risk Index supplemented by age, preoperative ECG, and presence of any type of

diabetes predicts long-term survival after major vascular surgery (40).

Rationale

• Patients with diabetes are at two to four times higher risk for having coexisting ischemic heart

disease and abnormal ECG results.

• ECG may reveal clues to suggest CAD, as patients with diabetes can have atypical or silent

symptoms of ischemia.

• ECG abnormalities such as previous MI (abnormal Q waves), ventricular ectopy, or atrial ectopy are

variables that have been used in various cardiac risk indices for noncardiac surgery, such as the

Revised Cardiac Risk Index and Eagle/L’Italien criteria for vascular surgery.

Comments

• If possible, preoperative ECG result should be compared to previous ECG readings to assess

important changes over time.







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3. Interventions to Decrease Risk Top

Control perioperative hyperglycemia to reduce rates of infection and mortality.

3.1 Optimize glycemic control before surgery.

Recommendations

• Achieve optimal control before elective procedures (HbA1c <7%, preprandial glucose <130 mg/dL,

and peak postprandial glucose <180 mg/dL).

• Recognize that glycemic goals may be less stringent in patients with frequent profound

hypoglycemia, elderly or young patients, patients with a limited life expectancy, or patients who

need surgery more urgently.

• Use details of the patient's current glycemic therapy to plan for perioperative glucose management.

• Discuss the risks and symptoms of hypoglycemia and cardiac ischemia when discussing other

general perioperative risks with the patient before surgery.

• Encourage patients with diabetes to monitor their own glucose levels the night before and the

morning of surgery, and to contact a physician if any low readings are found (<70 mg/dL or <4.0

mmol/L).

• Recommend that surgery be scheduled as early in the morning as possible to minimize disruption

in glycemic control.

Evidence

• In a case-controlled study of patients with deep sternal site infections after CABG, those with

diabetes with a preoperative glucose level >110 mg/dL had a higher risk for deep sternal wound

infections (OR, 1.4 [CI, 0.4 to 4.8]; P=0.6) (7).

• A prospective cohort study of outpatients showed that low self-monitored blood glucose levels

predicted severe episodes of hypoglycemia (stupor or unconsciousness) among patients with type

1 diabetes (21).

• The 2012 Standards of Medical Care in Diabetesfrom the American Diabetes Association suggest a

goal HbA1c of around 7.0% in most patients with diabetes (41).

Rationale

• Because patients will likely have altered their meal times and be fasting before surgery, glucose

should be monitored at home to ensure levels are not low; patients should be vigilant for early

symptoms of hypoglycemia before and after surgery.

• Early identification of hypoglycemia allows for prompt treatment to halt progression.

• Diabetic patients are at increased risk of having CAD, these patients need to be able to identify

symptoms of cardiac ischemia and to seek medical attention immediately.

• Determining details of outpatient therapy helps guide intraoperative diabetes management and

allow for accurate resumption of the patient's medication therapy in the postoperative phase.

• Early morning surgery, especially for procedures when the patient is expected to resume oral

intake on the same day, minimizes disruption in glucose reduction therapy and may help maintain

glycemic control.

3.2 Continue β-blockers perioperatively in diabetic patients who are already receiving them, but do not start β-blockers preoperatively.

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Recommendations

• Continue β-blockers during the perioperative period in patients who are already receiving them.

• Consider starting β-blockers only in patients with a nonsurgical indication such as heart failure or

CAD.

Evidence

• A 2008 systematic review of the effect of perioperative β-blockers on mortality included 33 trials

with 12,306 patients, and found that treatment with β-blockers did not lead to improved all-cause

or cardiovascular mortality. Treatment was associated with a decrease in nonfatal MI (NNT, 63)

and an increase in nonfatal stroke (NNH, 293) (42; 43).

• The 2009 update of the 2007 ACCF/AHA guideline on perioperative cardiac evaluation recommends

continuing β-blockers in patients who are already receiving them and considering β-blockers in

patients at high risk for cardiac complications or those undergoing high-risk surgery (26).

Rationale

• β-blockers may have benefits as well as harms in the perioperative setting.

• Patients receiving β-blockers may be harmed by their abrupt withdrawal.

3.3 Consult with the anesthesiologist to reduce the risk for hypoglycemia and electrolyte abnormalities.

Recommendations

• Consult with the anesthesiologist to ensure that:

Glucose levels are monitored at least every hour

If using insulin during surgery, potassium levels are measured every 4 to 6 hours during surgery and more

frequently if the patient has renal failure or is taking an ACE inhibitor or potassium-sparing diuretics

Glucose is measured in the recovery room immediately after surgery

Anion gap and serum bicarbonate levels are measured in patients undergoing procedures longer than 6 hours

Evidence

• Consensus.




Rationale

• As patients under anesthetic are unable to communicate, hypoglycemia may go undetected;

therefore, glucose levels should be monitored frequently during surgery.

• Insulin shifts potassium into the intracellular compartment; therefore, potassium levels should also

be monitored closely if patients are receiving intraoperative insulin, at least every 3 to 6 hours.

3.4 Withhold oral medication before surgery in patients with type 2 diabetes who use oral hypoglycemic agents alone for glycemic control.

Recommendations

• Hold metformin for 1 or more days before surgery.

• On the day before surgery, ask patients to continue their usual oral hypoglycemic agents other

than metformin.

• On the morning of surgery, withhold oral antidiabetic agents.




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• Plan to use dextrose-containing iv solutions in patients who have been on sulfonylureas.

• Never withhold basal insulin.

• See table Recommendations for Management of Diabetes Medications and Insulin Before Surgery

or a Procedure Requiring Fasting.

Evidence

• A 2011 systematic review evaluated perioperative medication management in order to make

recommendations for best practices, and made recommendations regarding specific agents. The

authors recommend holding metformin for 48 hours before surgery, although the recommendation

was based on little evidence (44).

Rationale

• On the day of surgery, patients will usually be missing or delaying breakfast; therefore, oral

hypoglycemic agents should be temporarily discontinued to prevent hypoglycemia.

Comments

• Common practice is to hold biguanides for only 1 day before surgery or just on the morning of

surgery.

• Generally, no preoperative drug interventions are needed for patients with type 2 diabetes treated

with diet alone.

• Some patients in this group are suboptimally treated for their hyperglycemia and are not taking

any insulin as outpatients; these patients may require insulin to control a significantly elevated

glucose level.

3.5 In patients receiving insulin, adjust insulin dosage before the surgical

procedure to avoid hypoglycemia.

Recommendations

• Withhold all oral hypoglycemic agents on the morning of surgery.

• Alter the dosage of insulin depending on the outpatient drug regimen:

In patients taking long-acting insulin (e.g., glargine or detemir), give their customary morning and/or evening dose; do not resume pre-meal bolus doses of short- or rapid-acting insulin until patients are eating

For patients taking intermediate-acting insulin or mixed intermediate-acting and short- or rapid-acting insulin, either:

o Administer half of the typical morning dose, or

o Calculate the patient's TDI:

Split the TDI into two equal parts of basal insulin (glargine or detemir) and prandial insulin (rapid-acting insulin analogs), the latter of which will be withheld until the patient eats/receives nutrition, or

Split the TDI into four equal parts of basal and prandial insulin given as regular insulin every 6 hours, with half of the regular insulin dose given as basal insulin and the other half withheld until the

patient eats/receives nutrition; thus, the patient will be given one-eighth of the TDI for basal insulin every 6 hours until eating

For patients on continuous subcutaneous insulin pumps, discontinue and disconnect the pump, and administer iv insulin or a dose of subcutaneous long-acting insulin (glargine or detemir) that equals their 24-hour subcutaneous basal infusion dose through the pump; calculation of the 24-hour basal insulin dose is held in the pump itself and can be accessed by the patient

• For patients in whom hypoglycemia is a concern while fasting on a typical basal insulin dose, test

the home insulin dose 5 to 7 days before surgery by having the patient fast at home, checking

fingerstick glucose frequently.

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• Reduce the amount of insulin given if the patient experiences frequent episodes of hypoglycemia in

outpatient management.

• Never withhold basal insulin therapy.

• See table How to Adjust Insulin While Fasting for a Procedure (Patient Information).

• See table Calculation of TDI.

• See table Acceptable Insulin Regimens for Different Inpatient Scenarios.



Evidence


• Adrenaline, cortisol, growth hormone, and glucagon are all stimulated by surgery or anesthesia.

These hormones, coupled with basal metabolic requirements, increase the need for insulin

perioperatively even if the patient is fasting (45).

Rationale

• Perioperative management of patients on insulin is largely empiric and should be based on

knowledge of the patient's basal glucose control, the known stress of surgery and anesthesia on

that control, and the patient's specific insulin regimen.

3.6 Recognize that patients with type 2 diabetes who are treated with diet

alone occasionally require drug intervention in the perioperative setting.

Recommendations

• Consider supplemental perioperative short- or rapid-acting insulin, regular or lispro, given

subcutaneously every 4 hours on correction-dose insulin for blood glucose levels above target.

• If correction-dose insulin is used longer than 24 hours, start scheduled insulin.

• Recognize that the frequent use of correction-dose insulin without scheduled insulin, previously

known as ‘sliding-scale insulin,’ is no longer the standard of care.

• Aim for intraoperative and postoperative glucose targets between 140 mg/dL and 180 mg/dL.

• Start iv saline infusions at 100 mL/h to 150 mL/h for preoperative and intraoperative hydration.

• Recognize that the use of iv insulin may be necessary to achieve tight glycemic control more safely

and quickly than subcutaneous insulin.

• See table Calculation of Correction-dose or Supplemental Insulin Dose.

• See table Extra Insulin to Give.

Evidence

• In a randomized trial, 60 patients with well-controlled type 2 diabetes on noninsulin outpatient

therapy were randomly assigned to either iv insulin infusion at 1.25 U/h, 10 U q2h, or saline

infusion during major surgery. Blood glucose concentrations were similar among the three groups.

There was a mild-to-moderate increase in ketone body production in the saline group, but this

increase did not lead to any deleterious consequences (46).

• A study of tight glycemic control in surgical patients admitted to an ICU found that nearly all

patients, regardless of history of diabetes, required intensive insulin therapy to maintain a blood

glucose level <110 mg/dL. In this study, only 13% of patients had a diagnosis of diabetes (2).

• The American Association of Clinical Endocrinologists and the American Diabetes Association

published a consensus statement on inpatient glycemic control (47).

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Rationale

• One study suggests that patients who do not require insulin or oral hypoglycemic agents as a part

of their outpatient regimen will generally not have significantly elevated glucose levels

perioperatively.

• The stress of surgery and pharmacologic agents given perioperatively can cause hyperglycemia in

patients with no known history of diabetes and in those with diabetes, regardless of previous

control or treatment.

Comments

• In assessing glycemic response to calculated correction-dose insulin and making dose adjustments,

it is important to do so in anticipation of, rather than in reaction to, glycemic needs, with the

dosage determined by glycemic response to preceding dosage(s).

3.7 Administer subcutaneous correction-dose insulin or an iv insulin infusion during minor or short surgical procedures in patients with diabetes treated

with insulin with or without oral hypoglycemic agents with target glucose between 140 mg/dL and 180 mg/dL.

Recommendations

• For minor surgery:

Administer supplemental short-acting regular, lispro, aspart, or glulisine insulin in a correction dose for elevated blood glucose levels

Hydrate with saline or dextrose-containing solutions at 100 mL/h to 150 mL/h

• For major surgery:

Start:

o Scheduled basal insulin in all patients

o Prandial insulin in all patients who eat, timed to the meal and what the patient eats

o Nutritional insulin in all patients who receive enteral or parenteral nutrition

Administer iv insulin infusion

Hydrate with saline or dextrose-containing solutions at 100 mL/h to 150 mL/h

• Aim for glucose targets between 140 mg/dL and 180 mg/dL.

• Recognize that the use of iv insulin may be necessary to achieve tight glycemic control more safely

and quickly than subcutaneous insulin.

• Continue scheduled basal insulin in all patients on insulin therapy. Never hold basal insulin therapy

in patients with type 1 diabetes.

• If a correction-dose of insulin is needed, use subcutaneous correction-dose insulin or iv insulin

infusion.

• Do not use correction-dose insulin (‘sliding-scale insulin’) alone without scheduled basal insulin.

• Use a dextrose-containing solution in patients on insulin infusions.

• See the Yale Insulin Infusion Protocol.


• See table Calculation of Correction-dose or Supplemental Insulin Dose.



Evidence

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• Consensus.

• In a randomized trial, 20 patients were assigned to subcutaneous insulin or iv insulin (GIK infusion)

during minor surgery under general anesthesia. The iv insulin group had significantly lower blood

glucose levels compared to the subcutaneous insulin group during the infusion period (P<0.05)

(48).

• A randomized trial of 30 patients with diabetes (some requiring and some not requiring insulin)

compared iv insulin infusion with a GIK drip or subcutaneous injections of insulin for elective major

surgery. There was no significant difference in glucose levels 24 hours before or 24 hours after

surgery. During surgery, 67% of the patients in the insulin infusion group were in the target range

of 90 mg/dL to 180 mg/dL, whereas only 40% of the subcutaneous injection group was in the

target range (49).

Rationale

• Oral agents are contraindicated for many reasons in patients undergoing surgery who may or may

not eat and who may or may not suffer complications that can make oral agents dangerous.

• Use of oral agents in patients who are not eating can cause hypoglycemia.

• Insulin is easier than oral agents to titrate rapidly and safely.

• For patients requiring insulin who are undergoing minor surgical procedures, continuous iv insulin

infusions will probably result in better control of glucose levels compared with subcutaneous

insulin; however, none of the evidence considers whether the somewhat better glucose control

achieved with iv insulin for minor surgical procedures results in outcome improvements such as

rate of infections, myocardial ischemia, or length of hospital stay.

• In the absence of such evidence, either subcutaneous or iv insulin infusions could be used.

Comments

• Correction doses of short- or rapid-acting insulin are determined by assessing responses to

previous doses so that insulin can be given in anticipation of, rather than in reaction to, glycemic

needs.

• Whether insulin infusion is used depends on the degree of hyperglycemia, the type of surgery

planned, and the kind of iv fluid being used (dextrose, iv alimentation fluid), regardless of the

preoperative regimen used for glycemic control.

• Patients undergoing cardiac surgery who are treated with iv insulin have a decreased rate of

sternal wound infection (50).

• Studies of insulin strategies have not evaluated important clinical outcomes such as mortality and

wound infections. The strategy of insulin administration needs to take into account practicality (i.e.,

whether there is ability to safely monitor glucose levels intraoperatively and on the hospital ward

postoperatively), and the physician's own judgment regarding the particular individual. The specific

recommendations presented here represent a practical and reasonable approach to management

(48; 49; 51).


it is important to do so in anticipation of, rather than in reaction to, glycemic needs.

• Whether insulin infusion is used depends on the degree of hyperglycemia and the kind of iv fluid

being used (dextrose, iv alimentation fluid) regardless of the preoperative regimen used for

glycemic control.

3.8 Use iv insulin infusions in patients with type 1 or type 2 diabetes treated

with insulin and undergoing major surgical procedures.

Recommendations



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• In patients with type 1 or type 2 diabetes treated with insulin who are undergoing complex major

surgical procedures such as CABG, use continuous iv insulin infusion hourly titrated based on point-

of-care glucose values and change.

• Measure blood glucose levels hourly and electrolyte levels every 4 to 6 hours.

• Give insulin in the morning before surgery as recommended in 3.5.

• Aim for glucose targets between 120 mg/dL and 180 mg/dL (6.7 mmol/L and 10.0 mmol/L).

Evidence

• A 2012 noninferiority randomized, controlled trial compared liberal (120 mg/dL to 180 mg/dL) with

tight (90 mg/dL to 120 mg/dL) glucose goals in 189 patients with diabetes undergoing CABG.

There were no differences in rates of infection between the groups, but the liberal group had fewer

episodes of hypoglycemia (52).

• A 2011 randomized, controlled trial compared liberal (120 mg/dL to 180 mg/dL) with tight (90

mg/dL to 120 mg/dL) glucose goals (achieved with insulin infusion) in 82 patients undergoing

CABG. There were no differences in the rates of major adverse events between the groups, but

there were fewer episodes of hypoglycemia in the tight control group (NNH 1.6) (53).

• A 2009 consensus statement from the American Association of Clinical Endocrinologists and the

American Diabetes Association recommends a goal glucose range of 140 mg/dL to 180 mg/dL (7.8

to 10.0 mmol/L) in critically ill patients, and a goal fasting glucose of <140 mg/dL (<7.8 mmol/L)

in non-critically ill patients, with random blood glucose levels <180 mg/dL (<10.0 mmol/L). The

guideline does not specifically address intraoperative and perioperative patients (47).

• In a prospective cohort study of 2402 diabetic patients undergoing CABG, 968 patients received

treatment with correction-dose insulin for the first 2 postoperative days, and 1499 patients

received continuous iv insulin infusion. There was a significant reduction in the incidence of deep

sternal wound infections in the group that received the insulin infusion (0.8% vs. 2.0%) (50). In a

subsequent study, the same team reported reduced mortality in diabetic patients undergoing CABG

(54).

• In 737 patients undergoing cardiac surgery, intra- and postoperative use of an insulin infusion

protocol designed to achieve blood glucose levels of <130 mg/dL more than 50% of the time was

accompanied by a reduction in the rate of mediastinitis from 1.6% (before initiation of the

protocol) to 0%. It is noteworthy that 57% of the patients meeting the 130 mg/dL threshold for

insulin therapy did not have a perioperative diagnosis of diabetes (55).

• The favorable effect on wound infection of postoperative continuous insulin infusion has also been

reported for 761 patients undergoing CABG, 37% of whom were diabetic. Target blood glucose was

120 mg/dL to 160 mg/dL. Before the use of the infusion protocol, the rate of wound infections was

significantly higher in the diabetic patients than in the nondiabetic patients. The use of the protocol

was associated with a reduction in the rate of wound infections in the diabetic patients to that

observed in the nondiabetic group (56).

Rationale

• For patients requiring insulin who undergo complex major surgical procedures, insulin infusions

tend to control blood glucose levels better than intermittent insulin therapy and likely reduce

perioperative infections.

Comments

• Because of consistent evidence showing the effectiveness and safety of meticulous glycemic control

in the intensive care setting, particularly in cases of cardiac surgery, and because of consensus

among experts (57), use an insulin infusion protocol in such a setting whenever possible. One

should consider its use even in patients without a pre-ICU diagnosis of diabetes when target

glycemia has been exceeded.

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• Note that potassium levels may need to be checked more frequently if the patient has renal failure

or is taking an ACE inhibitor, angiotensin-receptor blocking agent, or potassium-sparing diuretics.

• There are several different types of iv insulin infusions, each with its own benefits and

disadvantages.

There is no clearly superior choice in insulin infusions

There are multiple insulin infusion protocols, including the Yale Insulin Infusion Protocol and the Trence-Hirsch Example of an Intravenous Insulin Infusion

In assessing glycemic response to calculated correction-dose insulin and making dose adjustments, it is important to do so in anticipation of, rather than in reaction to, glycemic needs

Whether insulin infusion is used depends on the degree of hyperglycemia and the kind of iv fluid being used (dextrose, iv alimentation fluid) regardless of the preoperative regimen used for glycemic control

• Additional published examples of insulin infusion protocols that have been used successfully appear

in 58, 59, and 60.

3.9 Control postoperative glucose levels to reduce both cardiac and infectious

complications.

Recommendations

• Maintain postoperative glucose levels (pre-meal and fasting) in the range of 100 mg/dL to 180

mg/dL in patients undergoing surgical procedures that are not long or complex.

• Maintain postoperative glucose levels in the range of <140 mg/dL at pre-meal and fasting times in

patients undergoing cardiac surgery who are not critically ill.

• Recognize that iv insulin can be the safest way to titrate insulin when trying to obtain intensive

glucose targets.

• Consider more stringent targets in stable patients with previous tight glycemic control or those who

are pregnant.

• Consider less stringent targets for terminally ill patients.

• Do not use oral diabetes medications for the treatment of inpatient hyperglycemia; insulin is

preferred.

Evidence

• A 2012 guideline from the British Diabetes Society and the National Health Service recommends

goal blood glucose of 6 mmol/L to 10 mmol/L (100 mg/dL to 180 mg/dL) in the perioperative

period and states that a range of 4 mmol/L to 12 mmol/L (approximately 80 mg/dL to 200 mg/dL)

is acceptable (61).

• A prospective observational cohort study of 411 patients undergoing CABG found that increasing

glucose levels were associated with increased risk of infections (chest wounds, pneumonia, or UTI).

The odds of having an infection was 1.78 times higher if the glucose was 253 mg/dL to 352 mg/dL

(14 mmol/L to 20 mmol/L) compared to 121 mg/dL to 253 mg/dL (6.7 mmol/L to 14 mmol/L) (62).

• A 2010 systematic review evaluated the impact of intensive insulin therapy compared with

standard therapy in surgical patients. The meta-analysis was limited by heterogeneity but found no

mortality benefit with intensive therapy (RR, 0.85 [CI, 0.69 to 1.04]) (63).

• A randomized, controlled trial of hyperglycemic patients admitted postoperatively to a surgical ICU

compared intensive insulin therapy to conventional insulin therapy. For 1548 patients, who mostly

underwent elective cardiac surgery, the intensive insulin group (glucose, 80 mg/dL to 110 mg/dL

or 4.4 mmol/L to 6.1 mmol/L) had a 4.6% mortality rate compared to the conventional insulin

therapy group (glucose, 180 mg/dL to 200 mg/dL or 10 mmol/L to 11 mmol/L) who had an 8.0%

mortality rate (RR, 42%). The rate of sepsis was also lower with the intensive controlled group

compared with the conventional group (25% vs. 67%) (2).

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• A small, prospective, randomized study compared the effect of meticulous glycemic control

achieved by GIK infusion with standard therapy in 141 diabetic patients undergoing CABG. The GIK

group had significantly less atrial fibrillation, shorter hospital stay, fewer wound infections, fewer

episodes of recurrent ischemia, and increased survival over 2 years (64).

• The Normoglycemia Intensive Care Evaluation - Survival Using Glucose Algorithm Regulation

(NICE-SUGAR) study examined the effect of intensive vs. conventional glucose control on mortality

and morbidity in critically ill patients, the majority of whom were on mechanical ventilation.

Mortality, cardiovascular events, and hypoglycemia were higher in patients treated with intensive

insulin. The conventional arm aimed to keep blood glucose ≤180 mg/dL, and the intensive arm

aimed for glucose control between 80 mg/dL and 110 mg/dL (65).

Rationale

• Studies have suggested that significant hyperglycemia is associated with increased postoperative

infections.

• Patients undergoing cardiothoracic surgery appear to benefit from moderate glucose targets.

Comments

• Appropriate target blood glucose in surgical patients remains controversial.

3.10 Continue intraoperative management strategies into the postoperative period if the patient remains unable to eat normally.

Recommendations

• If the patient is fasting without caloric intake, continue to provide basal insulin with correction-dose

insulin if necessary.

• For patients undergoing more complex procedures on iv insulin infusions, continue infusion until

the patient is able to eat.

• Upon resumption of caloric intake, provide the three components of insulin requirements in the

hospital:

Basal insulin:

o Continue iv insulin (with subcutaneous prandial insulin when eating)

o Note the subcutaneous insulins used for basal insulin:

Glargine every 12 to 24 hours

Detemir every 12 hours

Regular every 6 hours

NPH twice a day

o Dose subcutaneous basal insulin by extrapolating 24-hour insulin use from the past 12 hours of iv insulin use

Prandial or nutritional insulin:

o Administer:

Rapid-acting insulin analogs (lispro, aspart, glulisine) before or after a meal, dosed according to how much the patient eats, or

Short-acting regular insulin with meals, dosed by doubling the regular insulin dose used for basal insulin

o Dose prandial insulin by the rule of 500 or by dividing the dose of insulin used for basal insulin by 3 (over 3 meals)

Correction-dose insulin:

o Match correction-dose insulin to the type of insulin used to cover prandial needs

o Dose correction-dose insulin by using the 5% rule or the rule of 1600

• Check the dose by calculating the TDI:



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0.3 U/kg·d in patients with type 1 diabetes

0.5 to 1.0 U/kg·d in patients with type 2 diabetes

• Do not stop iv insulin until basal insulin has been given for 1 to 3 hours (depending on the type of

basal insulin given).

• Check fingerstick glucose every hour for 3 hours after the first subcutaneous basal insulin injection

has been given; do not wean off of iv insulin until the blood glucose level is <150 mg/dL, which will

prevent hyperglycemia if an inadequate amount of basal insulin was given.

• See table Calculation of Correction Dose or Supplemental Insulin Dose.

• See table Calculation of Prandial Insulin Dose.

Evidence

• In a prospective cohort study of 2402 patients undergoing CABG, 968 patients received treatment

with correction-dose insulin for the first 2 postoperative days and 1499 patients received

continuous iv insulin infusion. There was a significant reduction in the incidence of deep sternal

wound infections in the group that received the insulin infusion (0.8% vs. 2.0%) (50).

• In a randomized trial of patients experiencing hyperglycemia, patients with stress-induced

hyperglycemia were successfully transitioned to detemir insulin at a dose of 50% of the previous

24-hour iv insulin requirements, in addition to using aspart insulin with a dose based on

carbohydrate intake. Patients with diabetes required a dose that was a higher percentage of the

previous 24-hour insulin requirements (66).

• The transition-to-target study did not find a significant difference in glucose control using a weight-

based regimen or transitioning at 60% or 80% of the previous 24-hour insulin use (67). If patient

is clinically stable and fasting, the Duke University Health System Diabetes Management Service

uses 100% of the TDI (68).

Rationale

• Patients may not be able to eat after surgery for a variety of reasons, such as nausea from

anesthesia or drug side effects, or development of ileus.

• It is important in the postoperative phase to maintain glucose in the target ranges (depending on

the surgery type) to minimize both hyper- and hypoglycemia and to decrease morbidity and

mortality.

• The approach to achieve these goals has to be tailored to the patient's level of insulin resistance.

Comments


it is important to do so in anticipation of, rather than in reaction to, glycemic needs.

• Whether insulin infusion is used depends on the degree of hyperglycemia and the kind of iv fluid

being used (dextrose, iv alimentation fluid) regardless of the preoperative regimen used for

glycemic control.

• Other regimens exist for the transitional period that begins when the patient resumes eating. One

such regimen calculates the expected 24-hour insulin requirement from the amount of insulin

infused during the last 6 to 8 hours. Eighty percent of this calculated 24-hour requirement is taken

as the new TDI; 50% of this amount is given as intermediate-acting insulin twice daily or once

daily as insulin glargine; the remaining 50% is given as prandial rapid-acting insulin analogs

(lispro, aspart, glulisine) (69).

3.11 Resume the patient's outpatient diabetic diet and treatment regimen once he or she is eating well.

Recommendations



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• Consult with the surgical team to ensure that patients with diabetes are given appropriate diabetic

diets (i.e., no concentrated sweets, controlled or fixed carbohydrate diet) when oral intake is

resumed.

• Guided by the patient's preoperative regimen, resume oral hypoglycemic agents only once the

patient is eating normally and has no contraindications to oral or other diabetes therapy.

• Do not restart metformin if there is renal insufficiency with creatinine clearance <60 mL/min,

hypoxia, hypotension, significant hepatic impairment, COPD, or HF.

• Be aware that sulfonylureas, meglitinides, and exenatide stimulate insulin secretion and may,

therefore, cause hypoglycemia; use these agents only when eating has been well established.

• Consider a step-up approach for those on high-dose sulfonylureas, administering doses at

increasing increments until the patient's usual dose is reached.

• Recognize that exenatide and pramlintide cause significant nausea, and may not be appropriate for

or tolerated by patients recovering from surgery.

• Be aware that metformin causes significant nausea, diarrhea, and abdominal bloating, and may not

be appropriate for or tolerated by patients recovering from surgery.

• Minimize the length of time spent on correction-dose insulin if the patient is able to eat.

• Review glucose levels and insulin doses every 12 to 24 hours, and if correction-dose insulin is used

frequently, increase the scheduled basal and prandial insulin doses to reflect and anticipate

increased insulin needs.

• If the patient did not have good glycemic control preoperatively or has had a complication that

would preclude using an outpatient regimen, discharge the patient on the inpatient regimen or a

modification of the outpatient regimen.

• Initiate basal insulin in patients with HbA1c levels >8% who have contraindications to outpatient

oral medications.

• Initiate basal and prandial insulin in patients with HbA1c levels >10% or contraindications to

outpatient oral medications.

Evidence


• In a prospective study of 47 patients with DKA, correction-dose insulin was associated with higher

median glucose values (262 mg/dL vs. 200 mg/dL) and longer length of hospital stay (6.3 vs. 4.4

days) compared to restarting outpatient drug therapy (70).

• In 171 patients with diabetes admitted to a medical unit, predictors of hyperglycemia included use

of correction dose alone (RR, 2.85; P<0.05) (71).

Rationale

• Diets designed for patients with diabetes minimize postoperative hyperglycemia.

• Correction-dose insulin regimens are practical for patients who are not eating for short durations;

however, once the patient begins eating, reintroducing outpatient hypoglycemic medications

reduces fluctuations in glucose and reduces length of hospital stay.



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4. Patient Counseling Top

Provide patients with information about their surgery, the importance of perioperative glucose control, and symptoms of hypoglycemia.

4.1 Discuss with patients the planned glycemic management strategy and

how to recognize hypoglycemia.

Recommendations

• Inform patients of the warning symptoms and signs of hypoglycemia and strategies to avoid and

relieve them.

• Instruct patients to regularly monitor their glucose levels when diet alterations are made before

surgery.

• Instruct patients to continue their usual diabetic diets and to follow the surgeon's advice regarding

when to stop eating.

• Instruct patients to alter their outpatient drug therapy before surgery (see information on

preoperative drug intervention).

• Consider referring patients with poor control of their diabetes or those who are newly diagnosed

with diabetes to patient education centers before or after the planned surgery.

• Arrange for inpatient diabetes self-management education before discharge from the hospital for

patients new to insulin therapy (initiated during the hospitalization).

Evidence

• In a prospective cohort study of 280 patients with diabetes, those who received automated self-

care assessment calls with nursing phone call follow-up had fewer symptoms of hypo- or

hyperglycemia (P<0.001) (72).

• In a case-controlled study of 21 patients who had severe hypoglycemia, patients were found to

have less knowledge about diabetes than those who did not experience severe hypoglycemia. The

investigators concluded that patients' lack of knowledge about the symptoms and signs of

hypoglycemia is strongly associated with development of hypoglycemia (73).

• A randomized, controlled trial of patients with HbA1c levels >8.5% were randomly assigned to

receive an intensive education program with structured curriculum or educational material. HbA1c

levels fell equally in both groups (−2.0%) at 12 months (P<0.001) (74).

• In a randomized, controlled trial of 170 patients with type 2 diabetes, patients were randomly

assigned to either individual or group educational settings. Both groups in the study had similar

improvements in knowledge, BMI, health-related quality of life and reduction in HbA1c compared to

baseline. HbA1c level at baseline fell from 8.5% ± 1.8% to 6.5 ± 0.8% at 6 months (75).

• A technical review discusses the importance of diabetes self-management education for the

hospitalized patient (57).

Rationale

• Because patients will not be eating, hypoglycemia may develop; educating patients on early

symptoms may prevent serious neuroglycopenia.

• Patients who understand what their management plan will be and how to avoid serious

complications may be better prepared for surgery.



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• The preoperative medical assessment provides patients with an opportunity to have their diabetes

management reviewed and an attempt to improve glycemic control.

Comments

• Patient education and perioperative management may be facilitated by a team approach, including

teaching competent adult patients about elements of self-management while hospitalized.

4.2 Use the perioperative setting to review strategies to prevent complications of diabetes.

Recommendations

• Use the perioperative setting to:

Review cardiac risk factors and appropriate risk reduction management, such as:

o Smoking cessation

o Lipid and BP control

o Regular physical activity

Review diabetes glucose goals, including:

o Fasting glucose goals

o Postprandial glucose goals

o HbA1c

o How to recognize and treat hypoglycemia

Review diabetic complications and appropriate management, such as screening according to accepted recommendations for:

o Diabetic nephropathy

o Peripheral neuropathy

o Foot care

o Infections

o Retinopathy

• See module Diabetes Mellitus, Type 1.

• See module Diabetes Mellitus, Type 2.

• See module Coronary Heart Disease.

Evidence

• In the Steno-2 study, 160 patients were randomly assigned to usual care vs. intensive, targeted,

multifactorial intervention on modifiable risk factors for cardiovascular disease in patients with type

2 diabetes and microalbuminuria. Intensive risk factor reduction targeted glycemic control, BP

control, dyslipidemia, microalbuminuria, and secondary prevention of cardiovascular disease with

aspirin. Patients assigned to intensive therapy had a significantly lower risk of cardiovascular

disease (hazard ratio, 0.42) (76).

• A post-test survey showed that simple postdischarge educational classes improved knowledge of

CAD and health-promoting behaviors (77).

• Studies on the prevention of foot ulceration using education in diabetes suggest that there may be

a short-term benefit to education (78).

Rationale

• The postoperative assessment provides an opportunity for the physician to provide risk-factor

reduction management to prevent progression of cardiac and diabetic complications.

Comments

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• The American Diabetes Association recommends statin therapy to achieve an LDL cholesterol target

<100 mg/dL and a BP target <130/80 mm Hg, ACE inhibitor or angiotensin-receptor blocker

therapy to achieve a BP target <130/80 mm Hg and reduce microalbuminuria, and aspirin therapy

if there are no contraindications. The ADA also recommends yearly dilated eye exam and nightly

foot exam.

• Starting medications that are considered the standard of care in patients with diabetes prevents

vascular complications.



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5. Follow-up Top

Evaluate patients daily after surgery for glycemic control and prevention of complications.

5.1 Monitor patients closely after surgery to optimize glycemic management.

Recommendations

• Monitor glucose levels frequently:

In patients who are eating, monitor glucose levels up to five times per day (pre-meal for breakfast, lunch,

and dinner as well as bedtime)

In patients who are not eating but are receiving continuous (24 h/d) parenteral or enteral nutrition,

monitor glucose every 4 to 6 hours

Check glucose at 3 AM if a change in basal insulin has been made or the patient has had hypoglycemia in the past 24 hours

Consider testing patients with type 1 diabetes even more frequently

• Adjust basal and prandial insulin at least daily, and review the total amount of correction-dose

insulin used in the past 12 to 24 hours and add it to the scheduled insulin dose.

• Administer insulin according to scheduled basal and prandial/nutritional needs, and give correction-

dose insulin if the blood glucose level is higher than the goal.

• Do not withhold basal insulin.

• Avoid the frequent use of correction-dose insulin alone (‘sliding-scale insulin’) without scheduled

basal insulin.

• Measure other electrolytes, such as potassium, as needed:

For patients on insulin infusions, measure potassium levels every 6 hours

Note that potassium levels may need to be checked more or less frequently depending on renal function and concomitant drug use, such as with ACE inhibitors, angiotensin-receptor blocking agents, potassium-sparing diuretics, or other diuretics

• Measure bicarbonate levels, ketones, and anion gap every other day or as needed for patients who

are insulin-deficient to monitor for DKA.

• Aim to keep glucose levels within the target ranges and avoid hypoglycemia and marked

hyperglycemia.

• Recognize factors that increase the risk of inpatient hypoglycemia:

Change in caloric intake

Taper in glucocorticoid dose

Failure to adjust insulin dose daily based on glucose trends

Use of ‘sliding-scale insulin’ alone for longer than 24 hours

Administration of meals and insulin dose at separate times

Use of sulfonylurea therapy in patients with renal or liver failure

Not adjusting therapy if there is renal or liver failure

• If postoperative hyperglycemia is difficult to control, consider diet, dextrose-containing solutions,

infection, or DKA as the cause of hyperglycemia.

• Follow dietary intake at least daily to guide reintroduction of outpatient medications.

• Reintroduce outpatient drug therapy as outlined in Postoperative Drug Intervention.



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Evidence

• The American Association of Clinical Endocrinologists and the American Diabetes Association

published a consensus statement on inpatient glycemic control (47).




• Achieving moderate-intensity glycemic control (target 110 mg/dL to 150 mg/dL) with iv insulin

followed by multiple daily injections of scheduled and prandial insulin compared to standard-

intensity glycemic control was associated with similar rates of hypoglycemia and decreased

incidence of infection and atrial fibrillation after cardiac surgery (79).

Rationale

• With careful follow-up, glucose levels can be better controlled and hypoglycemia and marked

hyperglycemia can be minimized.

5.2 Evaluate patients for postoperative cardiac and infectious complications.

Recommendations

• Use elements of the history, physical exam, and further testing as needed to assess for

postoperative MI, wound infection, or other infections.

• Recognize that hyperglycemia may be a sign of infection.

Evidence

• Consensus.

Rationale

• Because postoperative MI often occurs 2 days to 4 days postoperatively and may have atypical

symptoms, patients will need to be monitored for cardiac complications.

• Patients with diabetes may also develop postoperative wound infections or other infections.

https://www.aace.com/files/inpatientglycemiccontrolconsensusstatement.pdf



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References Top

1. Velanovich V. Preoperative laboratory screening based on age, gender, and concomitant medical diseases. Surgery.

1994;115:56-61. (PMID: 8284762)

2. van den Berghe G, Wouters P, Weekers F, Verwaest C, Bruyninckx F, Schetz M, et al. Intensive insulin therapy in the critically ill patients. N Engl J Med. 2001;345:1359-67. (PMID: 11794168)

3. Kitabchi AE, Umpierrez GE, Murphy MB, Barrett EJ, Kreisberg RA, Malone JI, et al. Hyperglycemic crises in patients with diabetes mellitus. Diabetes Care. 2003;26 Suppl 1:S109-17. (PMID: 12502633)

4. Malone ML, Gennis V, Goodwin JS. Characteristics of diabetic ketoacidosis in older versus younger adults. J Am Geriatr Soc. 1992;40:1100-4. (PMID: 1401693)

5. Slaughter MS, Olson MM, Lee JT Jr, Ward HB. A fifteen-year wound surveillance study after coronary artery bypass. Ann Thorac Surg. 1993;56:1063-8. (PMID: 8239800)

6. Richet HM, Chidiac C, Prat A, Pol A, David M, Maccario M, et al. Analysis of risk factors for surgical wound infections following vascular surgery. Am J Med. 1991;91:170S-172S. (PMID: 1928160)

7. Wilson SJ, Sexton DJ. Elevated preoperative fasting serum glucose levels increase the risk of postoperative mediastinitis in patients undergoing open heart surgery. Infect Control Hosp Epidemiol. 2003;24:776-8. (PMID: 14587944)

8. Eagle KA, Coley CM, Newell JB, Brewster DC, Darling RC, Strauss HW, et al. Combining clinical and thallium data optimizes preoperative assessment of cardiac risk before major vascular surgery. Ann Intern Med. 1989;110:859-66. (PMID: 2655519)

9. L’Italien GJ, Paul SD, Hendel RC, Leppo JA, Cohen MC, Fleisher LA, et al. Development and validation of a Bayesian model for perioperative cardiac risk assessment in a cohort of 1,081 vascular surgical candidates. J Am Coll Cardiol. 1996;27:779-86. (PMID: 8613603)

10. Lee TH, Marcantonio ER, Mangione CM, Thomas EJ, Polanczyk CA, Cook EF, et al. Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery. Circulation. 1999;100:1043-9. (PMID: 10477528)

11. Bucerius J, Gummert JF, Borger MA, Walther T, Doll N, Onnasch JF, et al. Stroke after cardiac surgery: a risk factor analysis of 16,184 consecutive adult patients. Ann Thorac Surg. 2003;75:472-8. (PMID: 12607656)

12. Kuan P, Bernstein SB, Ellestad MH. Coronary artery bypass surgery morbidity. J Am Coll Cardiol. 1984;3:1391-7. (PMID:

6609179)

13. Malone DL, Genuit T, Tracy JK, Gannon C, Napolitano LM. Surgical site infections: reanalysis of risk factors. J Surg Res. 2002;103:89-95. (PMID: 11855922)

14. Browne JA, Cook C, Pietrobon R, Bethel MA, Richardson WJ. Diabetes and early postoperative outcomes following lumbar fusion. Spine. 2007;32:2214-9. (PMID: 17873813)

15. Debing E, Aerden D, Van den Brande P. Diabetes mellitus is a predictor for early adverse outcome after carotid endarterectomy. Vasc Endovascular Surg. 2011;45:28-32. (PMID: 21156716)

16. Frisch A, Chandra P, Smiley D, Peng L, Rizzo M, Gatcliffe C, et al. Prevalence and clinical outcome of hyperglycemia in the perioperative period in noncardiac surgery. Diabetes Care. 2010;33:1783-8. (PMID: 20435798)

17. Székely A, Levin J, Miao Y, Tudor IC, Vuylsteke A, Ofner P, et al.; Investigators of the Multicenter Study of Perioperative Ischemia Research Group and the Ischemia Research and Education Foundation. Impact of hyperglycemia on perioperative mortality after coronary artery bypass graft surgery. J Thorac Cardiovasc Surg. 2011;142:430-7.e1. (PMID: 21497835)

18. Harris MI, Flegal KM, Cowie CC, Eberhardt MS, Goldstein DE, Little RR, et al. Prevalence of diabetes, impaired fasting glucose, and impaired glucose tolerance in U.S. adults. The Third National Health and Nutrition Examination Survey, 1988-1994. Diabetes Care. 1998;21:518-24. (PMID: 9571335)

19. MacLean DR, Petrasovits A, Nargundkar M, Connelly PW, MacLeod E, Edwards A, et al. Canadian heart health surveys: a profile of cardiovascular risk. Survey methods and data analysis. Canadian Heart Health Surveys Research Group. CMAJ. 1992;146:1969-74. (PMID: 1596846)

20. Foster DW, McGarry JD. The metabolic derangements and treatment of diabetic ketoacidosis. N Engl J Med. 1983;309:159-69. (PMID: 6408476)

21. Cox DJ, Kovatchev BP, Julian DM, Gonder-Frederick LA, Polonsky WH, Schlundt DG, et al. Frequency of severe hypoglycemia in insulin-dependent diabetes mellitus can be predicted from self-monitoring blood glucose data. J Clin Endocrinol Metab. 1994;79:1659-62. (PMID: 7989471)

22. Santell JP, Hicks RW, McMeekin J, Cousins DD. Medication errors: experience of the United States Pharmacopeia (USP) MEDMARX reporting system. J Clin Pharmacol. 2003;43:760-7. (PMID: 12856391)

23. Santell JP, Hicks R, Protzel M. Is your patient a diabetic? Watch that insulin dose! RN. 2003;66:92. (PMID: 14639991)

http://www.ncbi.nlm.nih.gov/pubmed?term=8284762

























of 44

24. Lauruschkat AH, Arnrich B, Albert AA, Walter JA, Amann B, Rosendahl UP, et al. Prevalence and risks of undiagnosed diabetes mellitus in patients undergoing coronary artery bypass grafting. Circulation. 2005;112:2397-402. (PMID: 16230496)

25. Ata A, Lee J, Bestle SL, Desemone J, Stain SC. Postoperative hyperglycemia and surgical site infection in general surgery patients. Arch Surg. 2010;145:858-64. (PMID: 20855756)

26. Fleisher LA, Beckman JA, Brown KA, Calkins H, Chaikof EL, Fleischmann KE, et al.; American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines; American Society of Echocardiography; American Society of Nuclear Cardiology; Heart Rhythm Society; Society of Cardiovascular Anesthesiologists; Society for Cardiovascular Angiography and Interventions; Society for Vascular Medicine; Society for Vascular Surgery. 2009 ACCF/AHA focused update on perioperative beta blockade incorporated into the ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery. J Am Coll Cardiol. 2009;54:e13-e118. (PMID: 19926002)

27. Boersma E, Poldermans D, Bax JJ, Steyerberg EW, Thomson IR, Banga JD, et al. Predictors of cardiac events after major vascular surgery: Role of clinical characteristics, dobutamine echocardiography, and beta-blocker therapy. JAMA. 2001;285:1865-73. (PMID: 11308400)

28. Kamalesh M, Matorin R, Sawada S. Prognostic value of a negative stress echocardiographic study in diabetic patients. Am Heart J. 2002;143:163-8. (PMID: 11773928)

29. Clarke RS. The hyperglycaemic response to different types of surgery and anaesthesia. Br J Anaesth. 1970;42:45-53. (PMID: 5416307)

30. Mehta S, Burton P. Effects of althesin anaesthesia and surgery on carbohydrate and fat metabolism in man. Br J Anaesth. 1975;47:863-9. (PMID: 1201163)

31. Barker JP, Robinson PN, Vafidis GC, Burrin JM, Sapsed-Byrne S, Hall GM. Metabolic control of non-insulin-dependent diabetic patients undergoing cataract surgery: comparison of local and general anaesthesia. Br J Anaesth. 1995;74:500-5. (PMID: 7772420)

32. Brandt M, Kehlet H, Binder C, Hagen C, McNeilly AS. Effect of epidural analgesia on the glycoregulatory endocrine response to surgery. Clin Endocrinol (Oxf). 1976;5:107-14. (PMID: 1269158)

33. Pomposelli JJ, Baxter JK 3rd, Babineau TJ, Pomfret EA, Driscoll DF, Forse RA, et al. Early postoperative glucose control predicts nosocomial infection rate in diabetic patients. JPEN J Parenter Enteral Nutr. 1998;22:77-81. (PMID: 9527963)

34. Munro J, Booth A, Nicholl J. Routine preoperative testing: a systematic review of the evidence. Health Technol Assess. 1997;1:i-iv; 1-62. (PMID: 9483155)

35. High glucose before surgery raises risk of dangerous complications. ScienceDaily [serial online]. October 16, 2006. [Full Text]

36. D’Ancona G, Bertuzzi F, Sacchi L, Pirone F, Stringi V, Arcadipane A, et al. Iatrogenic hypoglycemia secondary to tight glucose control is an independent determinant for mortality and cardiac morbidity. Eur J Cardiothorac Surg. 2011;40:360-6. (PMID: 21256761)

37. Lawrence VA, Gafni A, Gross M. The unproven utility of the preoperative urinalysis: economic evaluation. J Clin Epidemiol. 1989;42:1185-92. (PMID: 2511275)

38. David TS, Vrahas MS. Perioperative lower urinary tract infections and deep sepsis in patients undergoing total joint arthroplasty. J Am Acad Orthop Surg. 2000;8:66-74. (PMID: 10666654)

39. Ritter MA, Fechtman RW. Urinary tract sequelae: possible influence on joint infections following total joint replacement. Orthopedics. 1987;10:467-9. (PMID: 3575173)

40. Subramaniam B, Meroz Y, Talmor D, Pomposelli FB, Berlatzky Y, Landesberg G. A long-term survival score improves preoperative prediction of survival following major vascular surgery. Ann Vasc Surg. 2011;25:197-203. (PMID: 21315231)

41. American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care. 2011;35 Suppl 1:S11-63. (PMID: 22187469)

42. Bangalore S, Wetterslev J, Pranesh S, Sawhney S, Gluud C, Messerli FH. Perioperative beta blockers in patients having non-cardiac surgery: a meta-analysis. Lancet. 2008;372:1962-76. (PMID: 19012955)

43. McColl RJ, Dixon E. ACP Journal Club. Review: Perioperative beta-blockers provide no clear benefit in patients having noncardiac surgery. Ann Intern Med. 2009;150:JC3-4. (PMID: 19306485)

44. Castanheira L, Fresco P, Macedo AF. Guidelines for the management of chronic medication in the perioperative period: systematic review and formal consensus. J Clin Pharm Ther. 2011;36:446-67. (PMID: 21729111)

45. Hoogwerf BJ. Perioperative management of diabetes mellitus: striving for metabolic balance. Cleve Clin J Med. 1992;59:447-9. (PMID: 1468128)

46. Raucoules-Aimé M, Labib Y, Levraut J, Gastaud P, Dolisi C, Grimaud D. Use of i.v. insulin in well-controlled non-insulin-dependent diabetics undergoing major surgery. Br J Anaesth. 1996;76:198-202. (PMID: 8777097)












http://www.sciencedaily.com/releases/2006/10/061015213650.htm














of 44

47. Moghissi ES, Korytkowski MT, DiNardo M, Einhorn D, Hellman R, Hirsch IB, et al. American Association of Clinical Endocrinologists and American Diabetes Association consensus statement on inpatient glycemic control. Endocr Pract.

2009;15:353-69. (PMID: 19454396)

48. Christiansen CL, Schurizek BA, Malling B, Knudsen L, Alberti KG, Hermansen K. Insulin treatment of the insulin-dependent diabetic patient undergoing minor surgery. Continuous intravenous infusion compared with subcutaneous administration. Anaesthesia. 1988;43:533-7. (PMID: 3046411)

49. Pezzarossa A, Taddei F, Cimicchi MC, Rossini E, Contini S, Bonora E, et al. Perioperative management of diabetic subjects. Subcutaneous versus intravenous insulin administration during glucose-potassium infusion. Diabetes Care. 1988;11:52-8. (PMID: 3276477)

50. Furnary AP, Zerr KJ, Grunkemeier GL, Starr A. Continuous intravenous insulin infusion reduces the incidence of deep sternal wound infection in diabetic patients after cardiac surgical procedures. Ann Thorac Surg. 1999;67:352-60; discussion 360-2. (PMID: 10197653)

51. Jacober SJ, Sowers JR. An update on perioperative management of diabetes. Arch Intern Med. 2000;159:2405-11. (PMID: 10665888)

52. Desai SP, Henry LL, Holmes SD, Hunt SL, Martin CT, Hebsur S, et al. Strict versus liberal target range for perioperative glucose in patients undergoing coronary artery bypass grafting: a prospective randomized controlled trial. J Thorac Cardiovasc Surg. 2012;143:318-25. (PMID: 22137804)

53. Lazar HL, McDonnell MM, Chipkin S, Fitzgerald C, Bliss C, Cabral H. Effects of aggressive versus moderate glycemic control on clinical outcomes in diabetic coronary artery bypass graft patients. Ann Surg. 2011;254:458-63; discussion 463-4. (PMID: 21865944)

54. Furnary AP, Gao G, Grunkemeier GL, Wu Y, Zerr KJ, Bookin SO, et al. Continuous insulin infusion reduces mortality in patients with diabetes undergoing coronary artery bypass grafting. J Thorac Cardiovasc Surg. 2003;125:1007-21. (PMID: 12771873)

55. Carr JM, Sellke FW, Fey M, Doyle MJ, Krempin JA, de la Torre R, et al. Implementing tight glucose control after coronary artery bypass surgery. Ann Thorac Surg. 2005;80:902-9. (PMID: 16122452)

56. Hruska LA, Smith JM, Hendy MP, Fritz VL, McAdams S. Continuous insulin infusion reduces infectious complications in diabetics following coronary surgery. J Card Surg. 2005;20:403-7. (PMID: 16153268)

57. Clement S, Braithwaite SS, Magee MF, Ahmann A, Smith EP, Schafer RG, et al. Management of diabetes and hyperglycemia in hospitals. Diabetes Care. 2004;27:553-97. (PMID: 14747243)

58. Goldberg PA, Siegel MD, Sherwin RS, Halickman JI, Lee M, Bailey VA, et al. Implementation of a safe and effective insulin infusion protocol in a medical intensive care unit. Diabetes Care. 2004;27:461-7. (PMID: 14747229)

59. Najarian J, Swavely D, Wilson E, Merkle L, Wasser T, Quinn AH, et al. Improving outcomes for diabetic patients undergoing vascular surgery. Diabetes Spectrum. 2005;18:53-60. [Full Text]

60. Lien LF, Spratt SE, Woods Z, Osborne KK, Feinglos MN. Optimizing hospital use of intravenous insulin therapy: improved management of hyperglycemia and error reduction with a new nomogram. Endocr Pract. 2005;11:240-53. (PMID: 16006296)

61. Dhatariya K, Levy N, Kilvert A, Watson B, Cousins D, Flanagan D, et al.; Joint British Diabetes Societies. NHS Diabetes guideline for the perioperative management of the adult patient with diabetes. Diabet Med. 2012;29:420-33. (PMID: 22288687)

62. Golden SH, Peart-Vigilance C, Kao WH, Brancati FL. Perioperative glycemic control and the risk of infectious complications in a cohort of adults with diabetes. Diabetes Care. 1999;22:1408-14. (PMID: 10480501)

63. Friedrich JO, Chant C, Adhikari NK. Does intensive insulin therapy really reduce mortality in critically ill surgical patients? A reanalysis of meta-analytic data. Crit Care. 2010;14:324. (PMID: 21062514)

64. Lazar HL, Chipkin SR, Fitzgerald CA, Bao Y, Cabral H, Apstein CS. Tight glycemic control in diabetic coronary artery bypass graft patients improves perioperative outcomes and decreases recurrent ischemic events. Circulation. 2004;109:1497-502. (PMID: 15006999)

65. NICE-SUGAR Study Investigators, Finfer S, Chittock DR, Su SY, Blair D, Foster D, et al. Intensive versus conventional glucose control in critically ill patients. N Engl J Med. 2009;360:1283-97. (PMID: 19318384)

66. Dungan K, Hall C, Schuster D, Osei K. Differential response between diabetes and stress-induced hyperglycaemia to algorithmic use of detemir and flexible mealtime aspart among stable postcardiac surgery patients requiring intravenous insulin. Diabetes

Obes Metab. 2011;13:1130-5. (PMID: 21767340)

67. Shomali ME, Herr DL, Hill PC, Pehlivanova M, Sharretts JM, Magee MF. Conversion from intravenous insulin to subcutaneous insulin after cardiovascular surgery: transition to target study. Diabetes Technol Ther. 2011;13:121-6. (PMID: 21284478)

68. Dungan K, Hall C, Schuster D, Osei K. Comparison of 3 algorithms for Basal insulin in transitioning from intravenous to subcutaneous insulin in stable patients after cardiothoracic surgery. Endocr Pract. 2011;17:753-8. (PMID: 21550950)













http://spectrum.diabetesjournals.org/cgi/content/full/18/1/53












of 44

69. Bode BW, Braithwaite SS, Steed RD, Davidson PC. Intravenous insulin infusion therapy: indications, methods, and transition to subcutaneous insulin therapy. Endocr Pract. 2004;10(Suppl 2):71-80. (PMID: 15251644)

70. Gearhart JG, Duncan JL 3rd, Replogle WH, Forbes RC, Walley EJ. Efficacy of sliding-scale insulin therapy: a comparison with prospective regimens. Fam Pract Res J. 1994;14:313-22. (PMID: 7863803)

71. Queale WS, Seidler AJ, Brancati FL. Glycemic control and sliding scale insulin use in medical inpatients with diabetes mellitus. Arch Intern Med. 1997;157:545-52. (PMID: 9066459)

72. Piette JD, Weinberger M, McPhee SJ, Mah CA, Kraemer FB, Crapo LM. Do automated calls with nurse follow-up improve self-care and glycemic control among vulnerable patients with diabetes? Am J Med. 2000;108:20-7. (PMID: 11059437)

73. Schiel R, Müller UA, Ulbrich S. Long-term efficacy of a 5-day structured teaching and treatment programme for intensified conventional insulin therapy and risk for severe hypoglycemia. Diabetes Res Clin Pract. 1997;35:41-8. (PMID: 9113474)

74. Raji A, Gomes H, Beard JO, MacDonald P, Conlin PR. A randomized trial comparing intensive and passive education in patients with diabetes mellitus. Arch Intern Med. 2002;162:1301-4. (PMID: 12038949)

75. Rickheim PL, Weaver TW, Flader JL, Kendall DM. Assessment of group versus individual diabetes education: a randomized study. Diabetes Care. 2002;25:269-74. (PMID: 11815494)

76. Gaede P, Vedel P, Larsen N, Jensen GV, Parving HH, Pedersen O. Multifactorial intervention and cardiovascular disease in patients with type 2 diabetes. N Engl J Med. 2003;348:383-93. (PMID: 12556541)

77. Plach S, Wierenga ME, Heidrich SM. Effect of a postdischarge education class on coronary artery disease knowledge and self-reported health-promoting behaviors. Heart Lung. 1996;25:367-72. (PMID: 8886812)

78. Malone JM, Snyder M, Anderson G, Bernhard VM, Holloway GA Jr, Bunt TJ. Prevention of amputation by diabetic education. Am J Surg. 1989;158:520-3; discussion 523-4. (PMID: 2589581)

79. Leibowitz G, Raizman E, Brezis M, Glaser B, Raz I, Shapira O. Effects of moderate intensity glycemic control after cardiac surgery. Ann Thorac Surg. 2010;90:1825-32. (PMID: 21095319)

80. O’Malley CW, Emanuele M, Halasyamani L, Amin AN; Society of Hospital Medicine Glycemic Control Task Force. Bridge over troubled waters: safe and effective transitions of the inpatient with hyperglycemia. J Hosp Med. 2008;3(Suppl):55-65. (PMID: 18951384)















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Glossary Top

ACC/AHA American College of Cardiology/American Heart Association

ACE angiotensin-converting enzyme

bid twice daily

BMI body mass index

BP

blood pressure

BUN

blood urea nitrogen

CAD coronary artery disease

CDC Centers for Disease Control and Prevention

CI

confidence interval

COPD chronic obstructive pulmonary disease

DKA diabetic ketoacidosis

ECG electrocardiography

HbA1c glycosylated hemoglobin

HF heart failure

GIK glucose-insulin-potassium

ICU

intensive care unit

iv intravenous

LDL low-density lipoprotein

MI

myocardial infarction

NPH neutral protamine Hagedorn

OR odds ratio

RR risk ratio



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sc

subcutaneous

TDI total daily insulin dose

UTI urinary tract infection



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Tables Top

Recommendations for Management of Diabetes Medications and Insulin Before Surgery or a Procedure

Requiring Fasting

Medication Night Before Surgery Morning Before Surgery

Sulfonylurea:

Glyburide;Glipizide;Glimepiride

Give (usually given with meals) Hold

Metformin (contraindicated in men with creatinine levels ≥1.5

mg/dL and women with creatinine levels ≥1.4 mg/dL)

Hold Hold

Thiazolidinediones:

Rosiglitazone;Pioglitazone

May give; contraindicated in patients with class III-IV heart failure May give; very long acting; can cause fluid retention

Meglitinide:

Repaglinide;Nateglinide

Give with meals Hold

α-Glucosidase inhibitors:

Acarbose;Miglitol


Dipeptidal peptidase-IV inhibitor:

Sitagliptin


Incretin mimetics:

Exenatide

Give 30-60 min before meals Hold

Amylin analog:

Pramlintide

Give immediately before meals Hold

Regular insulin: Humulin® R

Novolin® R

ReliOn R

Give full dose Give half dose

NPH insulin: Humulin® N

Novolin® N

ReliOn N


Premixed insulins:

Humulin® 70/30

Novolin® 70/30

Humalog® 75/25

Novolog® 70/30


Rapid-acting insulin:

Aspart;Glulisine;Lispro; Inhaled insulin

Give full dose with meals Hold



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Basal insulin (long acting):

Glargine;Detemir

If patient is on basal insulin and rapid-acting insulin, give full dose.

If patient is on oral diabetes medications plus basal insulin or basal insulin only, give half dose

If patient is on basal insulin and rapid-acting insulin, give full dose.

If patient is on oral diabetes medications plus basal insulin or basal insulin only, give half dose

Continuous subcutaneous insulin infusion (insulin pump) Continue current settings Contact patient's diabetes provider for recommendations

Nothing replaces understanding the action of the different types of insulin and diabetes management in making appropriate clinical decisions about perioperative blood glucose control.

NPH = neutral protamine Hagedorn.



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How to Adjust Insulin While Fasting for a Procedure (Patient Information)

Insulin pump or insulin glargine

If you are on an insulin pump or take insulin glargine as your basal insulin, fasting for a procedure should be relatively easy, and you should not have to make changes in your insulin regimen unless your

basal insulin rates or dose is incorrect. If your basal insulin rates or insulin glargine dose is correct, take your normal amount of insulin glargine or continue your normal basal rates, but do not bolus with extra

insulin lispro or insulin aspart.

If you feel that it is unsafe for you to continue the same insulin glargine dose or basal insulin dose, then your basal insulin (either via pump or with insulin glargine) may be incorrect, and you should do a

fasting test a few weeks before the procedure.

If you are undergoing preparation for colonoscopy and you have been asked to consume only clear liquids (gelatin [such as Jell-O], ginger ale, chicken broth), eat gelatin and drink soda that has sugar in it at

meal time, and bolus appropriately depending on how many carbohydrates you eat. Between meals, drink sugar-free soda and eat gelatin (unless your blood glucose drops, in which case treat appropriately).

When you arrive at the test site, make sure that the nurses know you have diabetes, and ask them to monitor your blood glucose throughout the procedure. If your blood glucose is <100 mg/dL, you should

receive intravenous saline with a little bit of glucose (D5). Ask your driver to hold onto your glucometer in case the nurses at the test site do not check your fingerstick as frequently as you would like.

Other insulin regimens

If you take 70/30 insulin twice a day, take half of your dose of insulin the morning you start to fast. You should not need to halve your insulin the night before because you will have eaten dinner, and

everyone typically fasts overnight.

If you take regular insulin before meals and NPH insulin at bedtime, take a full dose of NPH insulin at bedtime, but take half of your dose of regular insulin at meal time (even though you are not eating).

If you are a big eater, this may indicate that most of the insulin you take is for the food you eat. If this is the case, you may want to consider taking just a quarter of your regular or 70/30 dose when fasting.

If you are undergoing preparation for colonosopy, you may want to see the recommendations above for those on insulin glargine or an insulin pump. If you do not know how to count carbohydrates, then eat

sugar-free gelatine and drink mostly chicken broth and sugar-free, clear soda. If your blood glucose drops below 100 mg/dL, you can drink 4 oz of soda with sugar in it (clear ginger ale or lemon-lime soda).

When you arrive at the test site, make sure that the nurses know you have diabetes, and ask them to monitor your blood glucose throughout the procedure. If your blood glucose is <100 mg/dL, you should

receive intravenous saline with a little bit of glucose (D5). Ask your driver to hold onto your glucometer in case the nurses at the test site do not check your fingerstick as frequently as you would like.

Oral medications

If you take oral medications for diabetes, you should not take them while you fast for a procedure or if you are drinking mostly clear liquids.

If you are undergoing preparation for colonoscopy, you should consume mainly sugar-free soda and gelatin during the day. Chicken broth has some calories, and you can drink that over something sweet. If

your blood glucose drops below 100 mg/dL, you can drink 4 oz of soda with sugar in it (clear ginger ale or lemon-lime soda).

NPH = neutral protamine Hagedorn.



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Calculation of TDI

Weight

Type 1 diabetes: 0.3-0.5 U/kg

Type 2 diabetes: 0.5-0.1 U/kg

Compare to:

Previous home regimen

If the home regimen insulin dose does not match what the above calculations indicate, consider the following:

Inquire if the patient ever skips insulin

Consider if the patient may have more insulin resistance

Consider if the patient may be eating a lot of calories and more than half of the home regimen insulin covers prandial needs

Previous insulin needs

Review the total amount of correction dose insulin used in the past 12-24 h and add it to the scheduled insulin dose

TDI = total daily insulin dose.



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Acceptable Insulin Regimens for Different Inpatient Scenarios

Clinical Setting Basal Insulin Prandial/Nutritional Insulin Correction Dose Insulin Notes

Eating meals

Type 1 diabetes

NPH bid Rapid-acting analog Rapid-acting analog

NPH at bedtime Regular Regular

Glargine every 24 h Rapid-acting analog Rapid-acting analog

Levemir every 12 h Rapid-acting analog Rapid-acting analog

iv Rapid-acting analog sc iv

Eating meals

Type 2 diabetes

NPH at bedtime Rapid-acting analog or regular Rapid-acting analog or regular

Glargine every 24 h Rapid-acting analog Rapid-acting analog

Levemir every 12-24 h Rapid-acting analog Rapid-acting analog

iv Rapid-acting analog sc iv

Not eating

Type 1 diabetes

Regular every 6 h Do not give prandial insulin if the patient is not eating or receiving

nutrition

Regular every 6 h

Glargine every 24 h Rapid-acting analog every 4 h

Levemir every 12 h Rapid-acting analog every 4 h

iv iv

Not eating

Type 2 diabetes

Regular every 6 h Do not give prandial insulin if the patient is not eating or receiving

nutrition

Regular every 6 h


Levemir every 12-24 h Rapid-acting analog every 4 h

iv iv

ICU iv unless tight glycemic control already

achieved by the above methods

Convert to sc once the patient is eating

or cover oral nutrition with sc rapid analogs as above

iv

Enteral feeds, continuous Regular every 6 h Regular every 6 h Administration of regular insulin every

6 h is preferred to cover caloric

transitional formula. If feeds are

stopped, the patient will need much

less than half for basal insulin


Levemir every 12 h



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Enteral feeds, bolus Regular every 6 h Regular every 6 h Administer regular insulin every 6 h for

enteral feed boluses every 3 h or a rapid-acting insulin analog for enteral

feed boluses every 4 h


Levemir every 12 h

bid = twice daily; ICU = intensive care unit; iv = intravenous; NPH = neutral protamine Hagedorn; sc = subcutaneous.



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Calculation of Correction Dose or Supplemental Insulin Dose

Rule of 1600

Divide 1600 by the TDI to find the correction factor, the number by which the blood glucose level will decrease with 1 U of insulin. For instance, if the patient is taking 50 U of insulin, 1600 divided by 50 is 32.

Write the correction scale based on the formula (blood glucose level − 150)/30

5% Rule

If the hospital protocol only allows correction scales based on 50, use the 5% rule to dose the correction scale. Take 5% of the TDI, which is the number to use between dose 201 and 250




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Extra Insulin to Give

Glucose Level (mg/dL) TDI 20 TDI 40 TDI 60 TDI x

150-200 1 1 2 0.5 x

201-250 1 2 3 1 x

251-300 2 4 6 2 x

301-350 3 6 9 3 x

351-400 4 8 12 4 x

>400 5 10 15 5 x




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Calculation of Prandial Insulin Dose

Rule of 500

Divide 500 by the TDI to obtain the insulin-to-carbohydrate ratio. For instance, if the patient's TDI is 40 U, 500 divided by 40 is 12.5; give 1 U per 12 g of total carbohydrate

Total prandial insulin should generally equal total basal insulin

If the staff is unable to count carbohydrates, approximate total prandial insulin needs by making it the same amount as total basal insulin needs. Thus, if the patient is taking 20 U of basal insulin daily, divide

20 by 3; give 6-7 U of prandial insulin per meal

Transitioning from iv insulin to sc insulin

If the patient had not been eating while on iv insulin and is not going to eat:

Add up the total amount of iv insulin used over the past 12 h and extrapolate the 24-h dose

Give that dose as glargine every 24 h or levemir every 12 h

Before shutting off the drip, check fingerstick glucose every hour for 3 h

If the blood glucose level increases or the patient remains on a significant amount of iv insulin, do not stop the iv infusion, but recalculate the sc dose to account for higher insulin needs

Glargine and levemir can be given every 12 h as necessary to wean patients off of iv insulin

If the patient has not been eating while on iv insulin but is about to eat, recognize that the iv insulin requirements were covering only basal insulin needs

Calculate basal insulin as above

Dose prandial insulin by reviewing the calculation of prandial infusion shown above

It is helpful to give prandial insulin immediately after a meal once it has been determined how many carbohydrates have been ingested or tolerated in an ill patient postoperatively

iv = intravenous; sc = subcutaneous; TDI = total daily insulin dose.



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Figures Top

HbA1C Guidance

HbA1C = glycosylated hemoglobin.

Reprinted from 80.

perioperative management of diabetes mellitus - cecitycecity.com/acp_pier/pdfs/pcperi879.pdf ·...

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