Management of Patients with Uncontrolled Diabetes for Anesthesia

Preoperative Assessment

Patients with uncontrolled diabetes should not be cleared for elective anesthesia until their blood glucose levels are adequately controlled, with a target HbA1c between 6-8% and blood glucose between 5-10 mmol/L, according to the American College of Anaesthesiologists 1, 2, 3
A recent HbA1c measurement is essential for determining perioperative risk and should be obtained for all diabetic patients before anesthesia, as recommended by the American College of Anaesthesiologists 3
An HbA1c value between 6-8% indicates good glycemic control and is reassuring about the quality of long-term treatment and patient compliance, as stated by the American College of Anaesthesiologists 3
If blood glucose is >16.5 mmol/L on the day of surgery, the procedure should be postponed and treatment with corrective insulin administered, according to the American College of Anaesthesiologists 2, 4

For emergency surgery, proceed with surgery regardless of glucose control and implement intensive insulin protocol during perioperative period, as recommended by the American College of Anaesthesiologists 1, 2
For elective surgery, if HbA1c is 6-8%, clear for anesthesia and implement standard perioperative glucose monitoring, according to the American College of Anaesthesiologists 2, 3
If HbA1c is >8%, for non-urgent procedures, postpone surgery and refer to diabetologist, as recommended by the American College of Anaesthesiologists 5, 3
If blood glucose on day of surgery is >16.5 mmol/L, postpone elective surgery, administer corrective insulin bolus, and refer to diabetologist, according to the American College of Anaesthesiologists 2, 4, 5

Target blood glucose range: 5-10 mmol/L, as recommended by the American College of Anaesthesiologists 2, 4
Monitor capillary blood glucose hourly during the procedure, especially for lengthy surgeries, according to the American College of Anaesthesiologists 2
Administer insulin (ultra-rapid analogue) bolus if blood glucose >10 mmol/L, as recommended by the American College of Anaesthesiologists 2
Resume oral feeding as soon as possible postoperatively, according to the American College of Anaesthesiologists 4
Continue regular blood glucose monitoring postoperatively, as recommended by the American College of Anaesthesiologists 4, 6

Referral to a diabetologist is recommended for known diabetes with preoperative glycemic imbalance (HbA1c <5% or >8%), diabetes discovered during pre-anesthesia evaluation, blood glucose >16.5 mmol/L on day of surgery, or difficulty resuming previous treatment regimen, according to the American College of Anaesthesiologists 5