What is the management of diabetes mellitus (DM) on the day of surgery?

From the Guidelines

The management of diabetes mellitus on the day of surgery should prioritize blood glucose levels between 100-180 mg/dL (5.6-10.0 mmol/L) to minimize perioperative complications, as recommended by the most recent guidelines 1. To achieve this, several strategies can be employed:

• Metformin should be held on the day of surgery, as recommended by recent guidelines 2, 3.
• SGLT2 inhibitors should be discontinued 3-4 days before surgery to avoid euglycemic diabetic ketoacidosis, as suggested by recent studies 2, 3.
• For insulin-dependent patients, 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 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 compared to reactive, correction-only short- or rapid-acting insulin coverage alone with no basal insulin dosing 1.
• Blood glucose should be monitored at least every 2-4 hours while the individual takes nothing by mouth, and short- or rapid-acting insulin should be administered as needed to maintain target glucose levels 1.
• Stricter perioperative glycemic goals are not advised, as they may not improve outcomes and are associated with increased hypoglycemia 1. By following these guidelines, healthcare providers can effectively manage diabetes on the day of surgery, minimizing the risk of perioperative complications and improving patient outcomes.

From the FDA Drug Label

Surgery and other procedures —Withholding of food and fluids during surgical or other procedures may increase the risk for volume depletion, hypotension, and renal impairment. Metformin hydrochloride tablets should be temporarily discontinued while patients have restricted food and fluid intake

The management of diabetes mellitus (DM) on the day of surgery involves temporarily discontinuing metformin hydrochloride tablets in patients who have restricted food and fluid intake, due to the risk of volume depletion, hypotension, and renal impairment 4.

From the Research

Management of Diabetes Mellitus on the Day of Surgery

The management of diabetes mellitus (DM) on the day of surgery involves several key considerations, including:

• Insulin dose adjustment to avoid hypoglycemia, particularly for patients with type 1 diabetes mellitus and exogenous insulin-requiring type 2 diabetes mellitus 5
• Providing sufficient insulin to suppress catabolic processes and prevent excessive lipolysis and ketogenesis 6
• Monitoring blood glucose levels and adjusting treatment accordingly to maintain glucose control 7, 8
• Using glucose-insulin-potassium infusion (GIK) as a management regimen to achieve acceptable control on the day of operation 9

Perioperative Management

Perioperative management of patients with DM involves:

• Assessing the patient's diabetes type and treatment regimen to determine the best course of action 6, 7
• Considering the use of newer insulin analogues and diabetes technology to maintain glucose control 8
• Developing a strategy for perioperative decision making, including recommendations for insulin administration 7
• Monitoring plasma potassium and sodium concentrations during GIK infusion to prevent electrolyte imbalances 9

Treatment Options

Treatment options for patients with DM on the day of surgery include:

• Insulin administration via various routes, including intravenous and subcutaneous injection 6, 7
• Use of GIK infusion to maintain glucose control and prevent hypoglycemia 9
• Adjustment of insulin doses based on the patient's individual needs and response to treatment 5, 8