How to manage a patient with hyperglycemia (elevated blood sugar) on the morning of surgery?

Management of Perioperative Hyperglycemia with FBS 130 mg/dl (7.2 mmol/L)

For a patient with fasting blood sugar of 130 mg/dl (7.2 mmol/L) on the morning of surgery, subcutaneous insulin should be administered according to a correction scale, and the surgery should proceed as scheduled. 1

Assessment of the Hyperglycemia

A fasting blood glucose level of 130 mg/dl (7.2 mmol/L) represents mild hyperglycemia that falls within acceptable perioperative ranges according to current guidelines. This level does not warrant postponement of surgery as it does not significantly increase perioperative risk 1.

The American Diabetes Association recommends perioperative blood glucose targets of 100-180 mg/dL (5.6-10.0 mmol/L) 2, and the patient's current glucose level falls well within this range.

Management Algorithm

1. Administer subcutaneous (SC) insulin using a correction dose based on the patient's blood glucose level 1

   • For mild hyperglycemia (130 mg/dl), a small correction dose of rapid-acting insulin is appropriate
   • Do not use IV insulin as this is typically reserved for severe hyperglycemia (>200 mg/dl), patients with type 1 diabetes undergoing major surgery, or critically ill patients 1

2. Continue with the scheduled surgery - do not postpone or reschedule to the end of the list 1

3. Monitor blood glucose every 2-4 hours while the patient is NPO 2

   • Continue monitoring during surgery
   • Avoid relying solely on continuous glucose monitoring for intraoperative monitoring 1

4. Post-surgical monitoring

   • 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 This Approach

The 2023 Diabetes Care guidelines specifically state that the target range for blood glucose in the perioperative period should be 100–180 mg/dL (5.6–10.0 mmol/L) 2. The patient's glucose level of 130 mg/dl falls within this range, making it safe to proceed with surgery.

Subcutaneous insulin is preferred over IV insulin for mild hyperglycemia as it provides adequate glucose control with less risk of hypoglycemia 1. Basal-bolus insulin regimens have been associated with improved glycemic outcomes and lower rates of perioperative complications compared with correction-only insulin coverage 2.

Potential Complications and Precautions

1. Risk of hypoglycemia

   • Monitor for hypoglycemia after insulin administration
   • Immediate treatment is required if glucose falls below 70 mg/dL 3
   • Symptoms may include sweating, drowsiness, dizziness, anxiety, tremor, and hunger 3

2. Avoid overly aggressive insulin therapy

   • Overly strict glycemic targets (<100 mg/dL) increase hypoglycemia risk without improving outcomes 1
   • Hypoglycemia carries greater perioperative risks than mild hyperglycemia 1

3. Surgical stress response

   • Be aware that surgical stress can increase blood glucose levels due to counterregulatory hormone release 2
   • This may necessitate additional monitoring and insulin adjustment during and after surgery

By following this approach, you can effectively manage the patient's mild hyperglycemia while minimizing risks and allowing the surgery to proceed as scheduled.