Perioperative Diabetes Management

Introduction to Guidelines

The American Diabetes Association recommends that for patients with diabetes undergoing surgery, metformin should be held on the day of surgery, SGLT2 inhibitors discontinued 3-4 days before surgery, and all other oral hypoglycemic agents held the morning of surgery, while insulin doses should be adjusted to 50% of NPH dose or 75-80% of long-acting analog insulin 1, 2, 3

The target blood glucose range in the perioperative period should be 100-180 mg/dL for patients with diabetes undergoing surgery 1, 3
The A1C goal for elective surgeries should be <8% for patients with diabetes whenever possible 2, 3
A preoperative risk assessment should be performed for patients with diabetes who are at high risk for ischemic heart disease and those with autonomic neuropathy or renal failure 2, 4

Metformin should be held on the day of surgery for patients with diabetes undergoing surgery 1, 2, 3
SGLT2 inhibitors must be discontinued 3-4 days before surgery due to risk of euglycemic ketoacidosis for patients with diabetes 1, 2, 3
For patients on NPH insulin, half of the usual dose should be given on the morning of surgery 1, 2, 3
For patients on long-acting insulin analogs, 75-80% of the usual dose should be given on the morning of surgery 1, 2, 3

Blood glucose should be monitored at least every 2-4 hours while the patient takes nothing by mouth for patients with diabetes undergoing surgery 1, 2, 3
Short- or rapid-acting insulin should be dosed as needed to maintain target glucose range for patients with diabetes undergoing surgery 1, 2, 3

Surgical stress and counterregulatory hormone release increase the risk of hyperglycemia, which is associated with increased mortality, infection, and length of stay for patients with diabetes undergoing surgery 1, 3
Patients receiving glucocorticoids during the perioperative period may require additional insulin to manage hyperglycemia for patients with diabetes 1, 3

Failing to discontinue SGLT2 inhibitors 3-4 days before surgery can lead to euglycemic diabetic ketoacidosis for patients with diabetes 1, 2, 3
Not reducing insulin doses appropriately can lead to hypoglycemia during the perioperative period for patients with diabetes 1, 3
Inadequate glucose monitoring during the perioperative period can result in undetected hypo- or hyperglycemia for patients with diabetes 1, 2, 3