Should we discontinue (dc) insulin for a patient going for surgery in 2 days as an inpatient?

Perioperative Insulin Management for Surgical Patients

No, insulin should not be discontinued for a patient going for surgery in 2 days as an inpatient. Instead, insulin therapy should be maintained with appropriate dose adjustments based on the type of insulin the patient is receiving.

Rationale for Continuing Insulin

Maintaining glycemic control during the perioperative period is essential for reducing surgical complications, including infections, poor wound healing, and increased mortality 1. Completely discontinuing insulin therapy could lead to dangerous hyperglycemia, which increases perioperative risk.

Specific Insulin Management Protocol

For Patients on Insulin (2 Days Before Surgery):

• Continue the patient's usual insulin regimen until the day of surgery
• Monitor blood glucose levels regularly (every 4-6 hours)
• Target blood glucose range: 100-180 mg/dL (5.6-10.0 mmol/L) 2

Day of Surgery:

1. Basal Insulin (Long-acting):

   • Give 75-80% of the usual dose of long-acting insulin analogs 2
   • Give 50% of the usual dose of NPH insulin 2

2. Bolus/Mealtime Insulin:

   • Hold all rapid-acting or short-acting insulin if NPO (nothing by mouth) 2
   • If eating, administer prandial insulin immediately after the patient eats, with dose adjusted to the amount ingested 2

3. Oral Antidiabetic Medications:

   • Hold all oral glucose-lowering agents on the morning of surgery 2
   • Metformin should be held on the day of surgery 2
   • SGLT2 inhibitors must be discontinued 3-4 days before surgery 2

Intraoperative Management

• Monitor blood glucose every 2-4 hours during surgery 2
• Administer short-acting or rapid-acting insulin as needed for hyperglycemia 2
• Target blood glucose range: 100-180 mg/dL (5.6-10.0 mmol/L) 2

Postoperative Management

• Resume basal-bolus insulin regimen as soon as the patient is stable 2
• For patients who are eating, align insulin injections with meals 2
• For patients with poor oral intake, administer basal insulin plus correction doses 2

Important Considerations

• Basal-bolus insulin regimens have been shown to improve glycemic control and reduce hospital complications compared to sliding scale insulin alone in surgical patients 2
• Avoid prolonged use of sliding scale insulin regimens as the sole treatment, as this approach is strongly discouraged 2
• Hypoglycemia is a significant risk during the perioperative period, so frequent monitoring is essential 2

Common Pitfalls to Avoid

1. Complete insulin discontinuation: This can lead to dangerous hyperglycemia and increased surgical risk
2. Overreliance on sliding scale insulin: This reactive approach is less effective than proactive basal-bolus regimens 3
3. Inadequate monitoring: Blood glucose should be checked at least every 2-4 hours while NPO 2
4. Poor coordination of insulin timing with meals: This can lead to hypo- or hyperglycemia 4
5. Using CGM alone for intraoperative monitoring: CGM should not be used as the sole method for glucose monitoring during surgery 2

By following these guidelines, you can maintain appropriate glycemic control in your surgical patient while minimizing the risks of both hyper- and hypoglycemia.