Perioperative Diabetes Management

Preoperative Optimization

The American Diabetes Association recommends targeting A1C <8% for elective surgeries to reduce surgical risk, mortality, and infection rates 1, 2, 4
Discontinue SGLT2 inhibitors 3-4 days before surgery to prevent life-threatening euglycemic diabetic ketoacidosis, which can occur even with normal glucose levels 1, 2, 6
Hold metformin and other oral agents on the day of surgery, with the exception of metformin which can be held only on the day of surgery 1, 2, 6
Reduce basal insulin by 25% the evening before surgery to achieve better perioperative glucose control with lower hypoglycemia risk compared to usual dosing 1, 2, 4, 7

Maintain glucose 100-180 mg/dL within 4 hours of surgery, and do not pursue stricter targets (<80-180 mg/dL) as they do not improve outcomes and significantly increase hypoglycemia risk 1, 2, 4, 7
Monitor blood glucose at least every 2-4 hours while patient is NPO, and administer short- or rapid-acting insulin as needed to maintain target range 1, 2, 4, 7

Use basal-bolus insulin regimens (basal insulin plus premeal short/rapid-acting insulin) rather than correction-only insulin in noncardiac general surgery patients, as this approach improves glycemic outcomes and reduces perioperative complications 1, 2, 3, 7
Maintain 100-180 mg/dL in the postoperative period, and continue monitoring every 2-4 hours while NPO 4, 7

Glucocorticoids induce hyperglycemia in 56-86% of hospitalized patients, increasing mortality and morbidity risk, and require substantial increases in prandial and correction insulin (40-60% or more) in addition to basal insulin 1, 2, 5
Administer basal insulin 2-4 hours before stopping IV insulin to prevent rebound hyperglycemia and recurrent ketoacidosis in patients with diabetic ketoacidosis (DKA) or hyperglycemic hyperosmolar state (HHS) 5

Never pursue glucose targets <100 mg/dL perioperatively, as this increases hypoglycemia without benefit 7
Never use correction-only insulin without basal insulin in general surgery patients, as this is associated with worse outcomes 1, 7
Never continue SGLT2 inhibitors within 3-4 days of surgery, as this poses a risk of euglycemic DKA 6
Never stop IV insulin without prior subcutaneous basal insulin administration, as this causes rebound hyperglycemia 5
Never fail to adjust insulin for glucocorticoid therapy, as this leads to severe hyperglycemia and complications 1, 2