From the Guidelines
For patients with diabetes undergoing surgery, a reduction of 25% of basal insulin given the evening before surgery is recommended to achieve perioperative blood glucose goals with a lower risk for hypoglycemia. When it comes to preoperative insulin instructions, it's crucial to consider the type of insulin and the timing of the surgery. According to the latest guidelines from the Diabetes Care journal 1, basal insulin plus pre-meal short- or rapid-acting insulin (basal-bolus) coverage is associated with improved glycemic outcomes and lower rates of perioperative complications. Some key points to consider include:
- Monitoring blood glucose at least every 2–4 hours while the individual takes nothing by mouth and administering short- or rapid-acting insulin as needed 1
- Avoiding stricter perioperative glycemic goals than 80–180 mg/dL (4.4–10.0 mmol/L) to prevent increased hypoglycemia 1
- Using basal-bolus insulin coverage for improved glycemic outcomes and lower rates of perioperative complications in individuals undergoing noncardiac general surgery 1 It's essential to follow the healthcare provider's personalized recommendations, as individual health needs, surgery type, and blood glucose control may vary. Additionally, patients should always bring their insulin and glucose monitoring equipment to the hospital. By following these guidelines and adjusting the insulin regimen accordingly, patients with diabetes can minimize the risk of hypoglycemia and hyperglycemia during the perioperative period.
From the Research
Pre-Operative Insulin Instructions
- The management of blood glucose levels is crucial for patients with diabetes undergoing surgery, as surgery can produce a diabetogenic response due to the elevation of counterregulatory hormones and suppression of endogenous insulin 2.
- A study comparing three evening insulin glargine dosing strategies for patients with type 1 and type 2 diabetes found no significant differences in target preoperative fasting blood glucose achievement among the strategies in both the insulin glargine-only group and the insulin glargine plus bolus group 3.
- Another study found that continuous subcutaneous insulin infusion (CSII) continuation or conversion to intravenous insulin infusions resulted in similar intraoperative glycemic control, while CSII suspension had a greater rate of hyperglycemia 4.
- A randomized controlled trial investigated three peri-operative treatment strategies for patients with type-2 diabetes mellitus undergoing non-cardiac surgery, including premedication with liraglutide, glucose-insulin-potassium infusion, or insulin bolus regimen, and found that liraglutide stabilized peri-operative plasma glucose levels and reduced peri-operative insulin requirements 5.
- The use of continuous subcutaneous insulin infusion with short-acting insulin analogues or human regular insulin has been shown to be effective and safe for managing diabetes mellitus, especially type 1 diabetes, with advantages including better control of postprandial hyperglycaemia and lower daily insulin requirement 6.
Key Considerations
- Patients with diabetes should receive sufficient insulin during the perioperative period to suppress catabolic processes and prevent excessive lipolysis and ketogenesis 2.
- The route of insulin administration is a major consideration, with options including continuous subcutaneous insulin infusion, intravenous insulin infusion, and insulin bolus regimens 2, 4, 5.
- The choice of insulin regimen should be individualized based on the patient's specific needs and medical history, with consideration of factors such as diabetes duration, anesthesia time, and preoperative blood glucose levels 3, 4.