What management strategies should be employed for a diabetic adult patient who is NPO for approximately 20 hours prior to surgery and has no anticipation for DKA?

Management of NPO Diabetic Patient Without DKA Risk

For a diabetic adult patient who is NPO for approximately 20 hours prior to surgery with no anticipated risk of DKA, glucose infusion is only necessary if the patient is on insulin therapy; non-insulin treated patients do not require glucose supplementation during fasting. 1

Critical Distinction Based on Diabetes Treatment

Patients on Insulin Therapy

• Initiate glucose infusion starting at 7:00 a.m. if the patient is NPO and treated with insulin 1
• Stop the glucose infusion if blood glucose exceeds 16.5 mmol/L (297 mg/dL) 1
• This applies to all insulin-treated patients, including those with Type 1 diabetes, Type 2 diabetes on insulin, and insulin pump users 1

Patients NOT on Insulin Therapy

• No glucose infusion is necessary for patients not using insulin, even during prolonged fasting 1
• This includes patients on metformin alone, other oral antidiabetic agents, or diet-controlled diabetes 1

Medication Management Prior to Surgery

Metformin

• Stop metformin the evening before surgery 1
• Do not restart before 48 hours for major surgery and only after confirming adequate renal function 1

Other Non-Insulin Antidiabetic Drugs

• Hold all other non-insulin treatments on the morning of minor or major surgery 1
• Important exception: If the patient took sulfonylureas or glinides before emergency surgery, glucose infusion must be initiated if they remain NPO, due to hypoglycemia risk 1

Insulin Management

• For Type 1 diabetes: basal insulin must NEVER be stopped due to the risk of ketoacidosis developing within hours 1
• Administer usual insulin dose the evening before surgery 1
• For insulin pump users, maintain the pump until arrival in the surgical unit to continue basal delivery 1

Monitoring Requirements

Preoperative Assessment

• Target blood glucose < 10 mmol/L (180 mg/dL) before intervention to decrease risk of death, infection, and prolonged hospital stay 1
• Monitor capillary blood glucose levels during the days immediately preceding the intervention 1

Day of Surgery

• Check blood glucose regularly if glucose infusion is running 1
• Adjust or stop glucose infusion based on blood glucose values (stop if >16.5 mmol/L) 1

Common Pitfalls to Avoid

Do not assume all diabetic patients need glucose infusion during fasting—this is a critical error that can lead to unnecessary hyperglycemia in non-insulin treated patients 1

Do not stop basal insulin in Type 1 diabetes patients, even for brief procedures, as insulin deficiency leads to ketoacidosis within a few hours 1

Do not forget that sulfonylureas and glinides carry hypoglycemia risk—if these were taken before emergency surgery, glucose infusion becomes necessary despite the patient not being on insulin 1

Special Considerations for Extended NPO Period

For the 20-hour NPO duration mentioned:

• The glucose infusion protocol (if indicated) should begin at 7:00 a.m. on the day of surgery 1
• This timing assumes morning surgery; adjust accordingly for afternoon procedures while maintaining insulin coverage 1
• Patients on insulin pumps can maintain basal delivery throughout the NPO period until arrival in the surgical unit 1