Perioperative Glucose Management for Diabetic Patients

Pre-Operative Glucose Management

The American Diabetes Association recommends that the target blood glucose range for diabetic patients in the perioperative period should be 100-180 mg/dL (5.6-10.0 mmol/L) 1, 2
The A1C target for elective surgeries should be <8% (63.9 mmol/L) whenever possible to reduce surgical risk 1, 2
Blood glucose should be maintained between 100-180 mg/dL (5.6-10.0 mmol/L) within 4 hours of surgery 1, 2
Stricter glycemic targets (<100 mg/dL) are not recommended as they increase the risk of hypoglycemia without improving outcomes 1, 3
Metformin should be held on the day of surgery, and SGLT2 inhibitors must be discontinued 3-4 days before surgery 1, 2
All other oral glucose-lowering agents should be held the morning of surgery, and half of NPH dose or 75-80% of long-acting insulin analog dose should be given based on clinical judgment 1, 2

The American College of Cardiology recommends maintaining blood glucose between 100-180 mg/dL (5.6-10.0 mmol/L) during surgery 4, 5
For cardiac surgery patients, intraoperative insulin infusion should be started and maintained with a goal of blood glucose <180 mg/dL 4
Continuous intravenous insulin is the preferred method for critically ill patients requiring insulin during surgery 6
Blood glucose should be monitored at least every 2-4 hours during surgery 1, 2

The American Diabetes Association recommends continuing to target blood glucose between 100-180 mg/dL (5.6-10.0 mmol/L) in the post-operative period 1, 2
For cardiac surgery patients, maintain insulin infusion into the early post-operative period with a goal of <180 mg/dL 4, 5
Basal-bolus insulin regimens have shown better outcomes than correction-only insulin regimens in non-cardiac surgery patients 1, 2
Blood glucose should be monitored at least every 2-4 hours while the patient is NPO and administer short or rapid-acting insulin as needed 1, 2

Reducing the evening pre-surgery insulin dose by 25% improves the likelihood of achieving target perioperative glucose levels with lower hypoglycemia risk 1, 2
For patients with stress hyperglycemia, similar glucose targets apply 4
Perioperative glycemic targets tighter than 80-180 mg/dL have not shown improved outcomes and are associated with increased hypoglycemia risk 1, 2
Continuous glucose monitoring (CGM) should not be used alone for glucose monitoring during surgery 2

Attempting to achieve overly tight glucose control (<140 mg/dL) increases hypoglycemia risk without clear benefit 5
Using correction-only insulin without basal insulin coverage in non-cardiac surgery patients is not recommended 1, 2
Not adjusting insulin doses based on anticipated changes in steroid dosing and other factors affecting glucose levels 1, 7