What are the euglycemic management guidelines for a patient undergoing total pancreatectomy, including insulin (intravenous regular insulin) administration and glucose supplementation, in the intraoperative and preoperative periods?

Euglycemic Management for Total Pancreatectomy: Preoperative and Intraoperative Guidelines

For patients undergoing total pancreatectomy, maintain blood glucose between 100-180 mg/dL (5.6-10.0 mmol/L) throughout the perioperative period using continuous intravenous insulin infusion with concurrent glucose administration, monitoring glucose every 1-2 hours. 1, 2

Preoperative Management

Medication Adjustments

• Hold metformin on the day of surgery 1
• Discontinue SGLT2 inhibitors 3-4 days before surgery 1
• Reduce long-acting insulin (glargine/detemir) to 75-80% of usual dose the morning of surgery 1
• Give one-half of NPH insulin dose if applicable 1
• Stop all oral glucose-lowering agents the morning of surgery 1

Scheduling and Fasting

• Schedule the patient as the first case of the morning to minimize fasting duration 1
• Initiate IV glucose infusion (equivalent to 4 g/hour) starting at 7:00 AM if the patient requires insulin and must remain NPO 1
• Stop glucose infusion only if blood glucose exceeds 16.5 mmol/L (297 mg/dL) 1

Target Glycemic Control

• Aim for HbA1c <8% (<63.9 mmol/L) for elective total pancreatectomy whenever possible 1
• Maintain blood glucose 100-180 mg/dL (5.6-10.0 mmol/L) within 4 hours of surgery 1

Intraoperative Management

Insulin Administration Protocol

• Use continuous intravenous regular insulin infusion throughout the procedure 1, 2
• Always administer IV insulin with concurrent IV glucose (4 g/hour) and electrolytes to prevent hypoglycemia and hypokalemia 1
• Ultra-rapid short-acting insulin analogues (lispro, aspart, glulisine) are preferred when given intravenously 1

Glucose Monitoring

• Monitor blood glucose every 1-2 hours during surgery using arterial or venous blood samples, not capillary fingerstick measurements 1, 2
• Capillary glucose readings overestimate blood glucose levels, especially with vasoconstriction—a fingerstick reading of 70 mg/dL should be considered hypoglycemia and verified with laboratory measurement 1
• Do not use continuous glucose monitoring (CGM) alone for glucose monitoring during surgery 1

Target Range and Rationale

• Maintain blood glucose 100-180 mg/dL (5.6-10.0 mmol/L) throughout the intraoperative period 1, 2
• Avoid stricter targets (80-180 mg/dL), as they do not improve outcomes and increase hypoglycemia risk 1
• The broader target of 90-180 mg/dL (5-10 mmol/L) represents the best compromise between reducing morbidity/mortality and avoiding hypoglycemia 1

Critical Safety Considerations

Hypoglycemia Management

• For blood glucose <60 mg/dL (3.3 mmol/L), administer 15-20 grams IV dextrose immediately, even without symptoms—total pancreatectomy patients have severely impaired counterregulatory responses and cannot mount appropriate glucagon or epinephrine responses 2, 3
• Recheck glucose every 15 minutes after hypoglycemia correction until glucose >100 mg/dL 2
• Total pancreatectomy patients have maximum glucagon increases of only 5 pg/mL during hypoglycemia compared to 121 pg/mL in normal individuals, and reduced epinephrine responses (278 pg/mL vs 858 pg/mL) 3

Electrolyte Monitoring

• Monitor potassium levels every 4 hours during insulin infusion to prevent insulin-induced hypokalemia 1
• Adjust electrolyte supplementation based on laboratory values 1

Insulin Pump Considerations

If the patient uses a personal insulin pump preoperatively, remove it with mandatory immediate transition to continuous IV insulin infusion at the start of the intervention 1

Evidence Quality and Nuances

The glycemic targets of 100-180 mg/dL are supported by high-quality guidelines from the American Diabetes Association 1 and French Society of Anaesthesia 1, with convergent recommendations. The NICE-SUGAR trial and subsequent studies demonstrated that stricter normoglycemia targets (80-120 mg/dL) increase severe hypoglycemia and possibly mortality without improving outcomes 1.

Total pancreatectomy patients represent a unique population with complete absence of both insulin and glucagon secretion 4, 5. Research shows these patients require approximately 1.20 units/kg/day of insulin during the immediate postoperative period with parenteral nutrition 4, but this is significantly lower than type 1 diabetes patients due to absent glucagon (which normally drives basal insulin requirements) 5. During hospitalization after total pancreatectomy, only 43.3% of glucose values fall within target range, and 45.2% of patients experience hypoglycemic events 4, underscoring the critical importance of frequent monitoring and the 100-180 mg/dL target range.