What is the recommended postoperative management of overt diabetes immediately after a caesarean section?

Postoperative Management of Overt Diabetes Immediately After Caesarean Section

Transition from IV insulin to subcutaneous basal-bolus insulin therapy immediately upon resumption of oral feeding, using approximately 50% of the total 24-hour IV insulin dose as long-acting basal insulin and 50% as rapid-acting prandial insulin, while maintaining continuous glucose monitoring every 1-2 hours to prevent both hyperglycemia and hypoglycemia. 1

Immediate Postoperative Monitoring

• Check capillary blood glucose immediately upon arrival to recovery and then every 1-2 hours during the acute postoperative phase, especially critical in insulin-treated patients due to risk of hypoglycemia unawareness. 2
• Increase monitoring frequency if the patient is on insulin or insulin secretagogues, as postoperative stress and altered oral intake significantly affect glucose levels. 2
• Continue IV insulin infusion until blood glucose levels are stable at ≤180 mg/dL (10 mmol/L). 1

Transition from IV to Subcutaneous Insulin

The critical transition should occur when the patient resumes oral feeding and blood glucose has been stable for at least 24 hours. 1

Calculating Subcutaneous Insulin Doses:

• If IV insulin was used for ≥24 hours: Calculate total 24-hour IV insulin dose. Give 50% as long-acting basal insulin and 50% as ultra-rapid acting analogue divided among meals. 1
• Alternative dosing: Some protocols recommend 80% of the IV dose as basal insulin with rapid-acting insulin added at the first meal. 1
• Stop IV insulin only when infusion rate is ≤0.5 IU/hour; if rate is ≥5 IU/hour, this indicates major insulin resistance and requires continued IV therapy. 1

Timing of Transition:

• Administer the first dose of long-acting basal insulin immediately after stopping the IV infusion, ideally at 20:00 hours for optimal 24-hour coverage. 1
• If transition occurs before 20:00 hours, adjust the initial dose proportionally and give the full dose at 20:00 hours. 1
• Give the first dose of ultra-rapid acting insulin at the first meal, adjusting for the quantity of carbohydrates ingested. 1

For Patients Not Previously on Insulin:

• If IV insulin was used for <24 hours and hyperglycemia persists postoperatively, initiate subcutaneous insulin at 0.5-1 IU/kg/day (half as basal, half as rapid-acting analogue). 1, 2
• Give only half the anticipated rapid-acting dose if the meal is light. 1

Management of Hypoglycemia

Administer glucose immediately if blood glucose is <60 mg/dL (3.3 mmol/L), even without clinical symptoms. 1, 2

• Prefer oral glucose (15-20g) if the patient is conscious and able to swallow. 1, 2
• Give IV glucose immediately if the patient is unconscious or unable to swallow, then transition to oral glucose when consciousness returns. 1, 2
• For blood glucose between 70-100 mg/dL (3.8-5.5 mmol/L), administer glucose only if the patient reports hypoglycemic symptoms. 1

Management of Hyperglycemia

Check for ketosis immediately in any patient with blood glucose >300 mg/dL (16.5 mmol/L) to rule out ketoacidosis. 1, 2, 3

• Measure serum electrolytes urgently if glucose >300 mg/dL to assess for hyperosmolar hyperglycemic state, which requires ICU-level care. 2, 3
• Initiate rapid-acting insulin analogue and ensure adequate hydration with 0.9% normal saline. 1, 2, 3
• In the presence of ketosis, suspect early ketoacidosis, call a duty physician, and start ultra-rapid insulin analogue immediately. 1

Fluid Management

• Use 0.9% normal saline as the primary IV fluid, especially given NPO status and surgical fluid losses typical after caesarean section. 2, 3
• Ensure adequate hydration to prevent dehydration-related hyperglycemia and to support lactation. 2, 3

Special Considerations for Insulin Pump Users

• Reconnect the personal insulin pump as soon as the patient can manage it autonomously. 1
• If the patient cannot manage the pump independently, initiate a basal-bolus subcutaneous insulin regimen immediately. 1

Critical Pitfalls to Avoid

• Never abruptly stop IV insulin without overlapping subcutaneous basal insulin, as this causes dangerous rebound hyperglycemia and potential ketoacidosis. 2, 3
• Do not ignore altered mental status—check blood glucose immediately and consider hyperosmolar state, particularly in Type 2 diabetes. 2, 3
• Avoid using sliding-scale insulin alone without basal insulin coverage, as basal-bolus regimens significantly improve glycemic control and decrease postoperative complications compared to intermittent rapid insulin injections. 1, 4
• Do not delay insulin intensification in patients with persistent hyperglycemia, as clinical inertia in the postoperative period is associated with worse outcomes. 5, 6

Ongoing Monitoring and Adjustment

• Continue frequent glucose monitoring throughout the postoperative hospitalization to detect both hyperglycemia and hypoglycemia. 1
• Adjust insulin doses based on blood glucose patterns over 24-48 hours. 2
• Maintain glucose targets of 140-180 mg/dL in the postoperative period, as this range balances infection risk reduction without excessive hypoglycemia. 3, 4