How to manage a patient with mild hyperglycemia (Fasting Blood Sugar 130 mg/dl) on the morning of surgery?

Management of Mild Hyperglycemia on the Morning of Surgery

For a patient with a fasting blood sugar of 130 mg/dl (7.2 mmol/L) on the morning of surgery, proceed with the scheduled surgery with subcutaneous insulin administration as needed. 1

Assessment of Perioperative Risk

The patient's blood glucose level of 130 mg/dl (7.2 mmol/L) represents mild hyperglycemia that falls within acceptable perioperative ranges according to current guidelines:

• The American Diabetes Association recommends perioperative blood glucose targets of 100-180 mg/dL (5.6-10.0 mmol/L) 1
• This level does not meet criteria for postponement, as it is:
  • Below the threshold for severe hyperglycemia (>200 mg/dL)
  • Not associated with ketosis or acidosis
  • Within manageable range with standard perioperative protocols

Management Algorithm

1. Proceed with Surgery

• The blood glucose of 130 mg/dl is within the acceptable perioperative range (100-180 mg/dL) 1
• No need to postpone the operation or reschedule to the end of the list

2. Insulin Management

• Administer subcutaneous (SC) insulin using correction doses based on the patient's blood glucose level 1
• For this level of hyperglycemia (130 mg/dl), a small correction dose of rapid-acting insulin is appropriate
• Monitor blood glucose every 2-4 hours while NPO 1

3. Intraoperative Monitoring

• Continue blood glucose monitoring during surgery
• Avoid using continuous glucose monitoring (CGM) alone for intraoperative monitoring 1
• Be prepared to administer additional correction doses if glucose rises above target range

4. Postoperative Care

• Resume regular glucose monitoring in recovery
• If the patient has diabetes, transition to their usual diabetes management regimen based on their preoperative HbA1c and glucose control 1

Rationale for SC vs. IV Insulin

Subcutaneous insulin is preferred over IV insulin in this scenario because:

1. The hyperglycemia is mild (130 mg/dl) and within the acceptable perioperative range
2. IV insulin infusion is typically reserved for:
   • Severe hyperglycemia (>200 mg/dl)
   • Patients with type 1 diabetes undergoing major surgery
   • Critically ill patients 1

Avoiding Common Pitfalls

• Do not postpone surgery for mild hyperglycemia (130 mg/dl) as this level does not significantly increase perioperative risk 1
• Do not initiate aggressive insulin therapy that could lead to hypoglycemia, which carries greater perioperative risks than mild hyperglycemia 1
• Avoid overly strict glycemic targets (<100 mg/dL) as they increase hypoglycemia risk without improving outcomes 1
• Monitor for hypoglycemia after insulin administration, as it requires immediate treatment if glucose falls below 70 mg/dL 2

By following this approach, you can safely manage a patient with mild hyperglycemia (FBS 130 mg/dl) on the morning of surgery without unnecessary delays or complications.