Perioperative Management of Diabetes

Introduction to Perioperative Diabetes Management

The American Diabetes Association, American Heart Association, and American College of Cardiology provide guidelines for the perioperative management of diabetes to minimize complications and improve patient outcomes, with a focus on individualized care plans 1, 2, 3, 4, 5, 6

Discontinue SGLT2 inhibitors 3-4 days before elective surgery to reduce the risk of euglycemic diabetic ketoacidosis (euDKA), with a Class 1 level of evidence indicating strong consensus, as recommended by the American College of Cardiology, American Heart Association, and American Diabetes Association 1, 2, 3, 4, 5, 6
Hold metformin on the day of surgery to reduce the risk of lactic acidosis, as recommended by the American Diabetes Association 4, 3, 5
Suspend other oral antidiabetics (sulfonylureas, meglitinides, DPP-4 inhibitors, thiazolidinediones, alpha-glucosidase inhibitors) on the morning of surgery, as recommended by the American Diabetes Association 4, 3, 5
Suspend GLP-1 receptor agonists on the morning of surgery due to limited data on their safe use in the perioperative period, according to the American Diabetes Association 4, 3, 5
Patients with heart failure on SGLT2 inhibitors should balance the risk of ketoacidosis against the risk of worsening heart failure from medication cessation, and more careful monitoring may be warranted if the decision is made to continue the medication, as recommended by the American Society of Anesthesiologists 6
Patients with autonomic neuropathy or renal insufficiency should undergo preoperative risk evaluation, as recommended by the American Diabetes Association 5

Capillary glucose should be measured on admission to the surgical unit, and glucose levels should be monitored every 1-2 hours during surgery to maintain levels between 80-180 mg/dL (4.4-10.0 mmol/L) 7, 5
Maintain blood glucose between 100-180 mg/dL (5.6-10.0 mmol/L) during surgery, as recommended by the American College of Physicians and the American Diabetes Association 4, 2, 3, 5
Administer short-acting or rapid-acting insulin as needed to maintain target glucose levels, as recommended by the American Diabetes Association 4, 2, 3, 5
Use a basal-bolus insulin regimen to improve glucose control and reduce perioperative complications, as recommended by the American Diabetes Association 4, 3
Most patients require crystalloids at a rate of 1-4 ml/kg/h to maintain homeostasis, as recommended by 8

Glucose monitoring should continue every 4-6 hours until stabilization, and restart SGLT2 inhibitors only when the patient is eating and drinking normally (usually 24-48 hours after surgery), capillary ketones are <0.6 mmol/L, and no signs of metabolic derangement are present, as recommended by the American Society of Anesthesiologists and American College of Cardiology 6, 2, 4, 3, 1
Monitor for signs of euDKA (nausea, vomiting, tachypnea, anion gap metabolic acidosis) even with normal glucose levels, as recommended by the American Society of Anesthesiologists 6
Provide written sick-day rules to patients at discharge to minimize the risk of perioperative complications, as recommended by the American Society of Anesthesiologists 6

Patients with diabetic nephropathy are at increased risk of acute kidney injury and require preoperative evaluation of glomerular filtration rate, according to the American Society of Anesthesiologists 9
Risk factors that require special attention include renal insufficiency, dehydration, prolonged fasting, and concomitant use of medications that affect renal function (ACE inhibitors, diuretics, NSAIDs), as recommended by 9
Ensure proper hydration and minimize fasting time to reduce the risk of euDKA, as recommended by the American Society of Anesthesiologists 6
Consider glucose-containing IV fluids to mitigate ketone generation during unavoidable prolonged fasting, as recommended by the American Society of Anesthesiologists 6
Be vigilant for signs of euglycemic diabetic ketoacidosis (eDKA) even with normal glucose levels in emergency surgeries, as recommended by the American College of Cardiology, American Diabetes Association, and American Heart Association 2, 4, 3, 1
SGLT2 inhibitors increase the risk of perioperative diabetic ketoacidosis (DKA), particularly euglycemic DKA, with a 48% higher risk in patients taking SGLT2 inhibitors compared to those who are not (1.02 vs. 0.69 per 1000 patients), as noted by the American Society of Anesthesiologists 6