Perioperative Management of Diabetes Mellitus

 

Perioperative Management of Diabetes Mellitus: An Evidence-Based Review

Dr Neeraj Manikath ,Claude.ai

Abstract

Diabetes mellitus affects approximately 537 million adults worldwide and is associated with significant perioperative morbidity and mortality. Appropriate glycemic management during the perioperative period is essential to reduce adverse outcomes. This review summarizes current evidence-based approaches to the perioperative management of patients with type 1 and type 2 diabetes, focusing on preoperative assessment, intraoperative glycemic control, and postoperative management strategies. Recent guidelines and consensus statements are reviewed, with special attention to emerging technologies and pharmacological advancements that have improved perioperative care. The evidence supports individualized approaches to glycemic targets, medication management, and monitoring protocols based on surgical risk, diabetes type, and patient comorbidities. Implementation of standardized perioperative protocols has been shown to improve outcomes, though significant variation in practice patterns persists. This review provides a comprehensive framework for clinicians to optimize perioperative diabetes management across the surgical continuum of care.

Keywords: diabetes mellitus, perioperative care, glycemic control, insulin therapy, surgical outcomes

Introduction

Diabetes mellitus affects more than 537 million adults globally, with projections suggesting this number will rise to 783 million by 2045 (International Diabetes Federation, 2021). Patients with diabetes undergo surgical procedures at a higher rate than the general population and face increased perioperative risks, including surgical site infections, cardiovascular events, acute kidney injury, and mortality (Duggan et al., 2017; Frisch et al., 2010). These risks are compounded by the metabolic stress response to surgery, which is characterized by insulin resistance, hyperglycemia, and altered counter-regulatory hormone secretion (Ljungqvist et al., 2018).

Perioperative glycemic management requires balancing the risks of hyperglycemia against those of hypoglycemia while accounting for fasting requirements, medication adjustments, and the metabolic impact of surgical stress. Recent advances in diabetes technologies, including continuous glucose monitoring (CGM) systems and automated insulin delivery, offer new approaches to perioperative management (Pasquel et al., 2020). Additionally, newer antihyperglycemic agents have altered the landscape of perioperative diabetes care, necessitating updated evidence-based guidelines.

This review synthesizes current evidence regarding the perioperative management of both type 1 and type 2 diabetes mellitus, with emphasis on practical approaches across the preoperative, intraoperative, and postoperative periods. We aim to provide clinicians with an evidence-based framework for optimizing perioperative outcomes in this high-risk population.

Preoperative Considerations

Risk Assessment and Glycemic Targets

Preoperative risk stratification is essential for optimizing perioperative diabetes management. Major risk factors include poor preoperative glycemic control (HbA1c >8.5%), history of severe hypoglycemia, impaired awareness of hypoglycemia, presence of micro- and macrovascular complications, and complexity of the planned procedure (Duggan et al., 2017; Membership of the Working Party et al., 2021).

The American Diabetes Association (ADA) and the American College of Surgeons recommend achieving preoperative HbA1c levels below 8.0% when possible, though the evidence supporting specific HbA1c thresholds remains limited (ADA, 2024; Buchleitner et al., 2012). The Association of Anaesthetists of Great Britain and Ireland (AAGBI) guidelines further suggest that elective surgery should be postponed for patients with HbA1c >8.5% (69 mmol/mol) when the benefits of improved glycemic control outweigh the risks of surgical delay (Membership of the Working Party et al., 2021).

Preoperative glycemic targets should be individualized based on the patient's usual glycemic control, comorbidities, and planned procedure. Generally, a fasting glucose target of 5.0-10.0 mmol/L (90-180 mg/dL) balances the risks of perioperative hyper- and hypoglycemia (Duggan et al., 2017; Umpierrez et al., 2012).

Medication Management

Type 1 Diabetes

For patients with type 1 diabetes, maintaining basal insulin is essential to prevent diabetic ketoacidosis (DKA). Current evidence supports:

1. Multiple Daily Injections (MDI): Patients should continue their basal insulin (glargine, detemir, degludec) at 80-100% of the usual dose on the day of surgery (Partridge et al., 2021). For NPH insulin, a 20-25% reduction in dose is recommended (Membership of the Working Party et al., 2021).

2. Continuous Subcutaneous Insulin Infusion (CSII/insulin pump): For minor procedures, patients may continue pump therapy with close monitoring. For major surgery, transition to intravenous insulin infusion is recommended (Goel et al., 2023; Nassar et al., 2022).

3. Hybrid Closed-Loop Systems: Limited evidence supports maintaining these systems during minor procedures, with case reports demonstrating safety and efficacy (Partridge et al., 2021; Umpierrez & Klonoff, 2018). However, most centers disconnect these systems for major procedures to transition to intravenous insulin.

Type 2 Diabetes

Preoperative management of oral antihyperglycemic agents and non-insulin injectables varies based on the agent's mechanism of action and the surgical context:

1. Metformin: Traditional recommendations to discontinue metformin 24-48 hours before surgery have been challenged by recent evidence. Current guidelines suggest continuing metformin until the day before surgery unless contrast agents will be used or the patient has significant renal impairment (eGFR <30 mL/min/1.73m²) (ADA, 2024; Duggan et al., 2017).

2. Sulfonylureas and Meglitinides: These should be omitted on the day of surgery due to hypoglycemia risk (Duggan et al., 2017; Membership of the Working Party et al., 2021).

3. SGLT-2 Inhibitors: These should be discontinued 3-4 days before surgery due to the risk of euglycemic DKA, particularly in catabolic states (Thiruvenkatarajan et al., 2019; Membership of the Working Party et al., 2021).

4. GLP-1 Receptor Agonists: Weekly preparations should be discontinued 7 days before major surgery, while daily preparations can be held just on the day of surgery (Duggan et al., 2017).

5. DPP-4 Inhibitors: These can generally be continued until the day before surgery (ADA, 2024).

6. Thiazolidinediones: These should be discontinued 24-48 hours before surgery due to fluid retention concerns (Membership of the Working Party et al., 2021).

7. Insulin (Type 2 Diabetes): Similar to type 1 diabetes, basal insulin should be continued at 80% of the usual dose. Prandial insulin should be withheld while NPO (Duggan et al., 2017).

Preoperative Fasting and Carbohydrate Loading

Enhanced Recovery After Surgery (ERAS) protocols have modified traditional fasting practices, with strong evidence supporting a reduction in preoperative fasting times to 2 hours for clear liquids and 6 hours for solid food (Ljungqvist et al., 2018). For patients with diabetes, carbohydrate loading remains controversial but may be appropriate for selected patients with well-controlled type 2 diabetes (Jones et al., 2011). Limited evidence exists regarding carbohydrate loading in type 1 diabetes (Ackland et al., 2019).

Surgical Scheduling

When possible, patients with diabetes should be scheduled for the first surgical case of the day to minimize fasting duration and disruption of glycemic control (Duggan et al., 2017). For patients requiring prolonged fasting, admission the day before surgery may be necessary to establish glycemic control with intravenous insulin (Membership of the Working Party et al., 2021).

Intraoperative Management

Glycemic Targets

Intraoperative glycemic targets remain a subject of debate. Following the NICE-SUGAR trial, which demonstrated increased mortality with intensive glucose control in critically ill patients, most guidelines now recommend moderate glycemic targets of 7.8-10.0 mmol/L (140-180 mg/dL) during surgery (NICE-SUGAR Study Investigators, 2009). Tighter control (6.1-7.8 mmol/L or 110-140 mg/dL) may be appropriate for cardiac surgery patients, though the evidence remains mixed (Duggan et al., 2017; Umpierrez et al., 2012).

Monitoring Protocols

Intraoperative glucose monitoring frequency should be determined by the patient's glycemic stability, diabetes type, and surgical complexity:

1. Type 1 Diabetes: Glucose should be monitored hourly during surgery, regardless of procedure complexity (Membership of the Working Party et al., 2021).

2. Type 2 Diabetes: For major surgery, hourly monitoring is recommended. For minor procedures, every 2 hours may be sufficient if glucose values remain stable (Duggan et al., 2017).

3. Continuous Glucose Monitoring (CGM): Emerging evidence supports the use of CGM in the perioperative period, though concerns regarding accuracy during hemodynamic instability persist (Galindo et al., 2020; Umpierrez & Klonoff, 2018). A recent systematic review by Galindo et al. (2020) found that CGM devices maintain reasonable accuracy during surgery, but traditional point-of-care testing remains the standard for critical decision-making.

Insulin Administration

Insulin management during surgery depends on the procedure duration, complexity, and patient characteristics:

1. Minor Procedures (<2 hours, minimal metabolic stress): Subcutaneous basal insulin with correction doses may be sufficient (Umpierrez et al., 2012).

2. Major Procedures (>2 hours, significant metabolic stress): Intravenous insulin infusion is recommended, particularly for patients with type 1 diabetes, poorly controlled type 2 diabetes (HbA1c >8.5%), or those undergoing cardiac, transplant, vascular, or neurosurgical procedures (Membership of the Working Party et al., 2021).

3. Insulin Infusion Protocols: Computerized protocols have demonstrated superior glycemic control compared to paper-based protocols, with reduced hypoglycemia risk (Lanspa et al., 2015). The most widely validated protocol is the Yale Insulin Infusion Protocol, which adjusts insulin rates based on current glucose value, previous glucose value, and current insulin infusion rate (Shetty et al., 2012).

Fluid Management

Dextrose-containing fluids should be administered judiciously during surgery in patients with diabetes. In patients requiring insulin infusions, concomitant dextrose 5% infusion at 100-125 mL/hour helps prevent hypoglycemia while allowing insulin titration to control hyperglycemia (Membership of the Working Party et al., 2021). In patients with significant hyperglycemia (>13.9 mmol/L or >250 mg/dL), dextrose-containing fluids should be avoided until glucose levels decrease (Duggan et al., 2017).

Postoperative Management

Transition from Intravenous to Subcutaneous Insulin

Transition from intravenous to subcutaneous insulin requires careful planning to prevent rebound hyperglycemia or hypoglycemia. Current evidence supports:

1. Calculating Total Daily Dose (TDD): The 24-hour insulin requirement should be calculated from the intravenous infusion rate during the final 6-8 hours of stability (Umpierrez et al., 2012).

2. Distribution of Subcutaneous Insulin: Typically, 50% of TDD is given as basal insulin, with the remainder as prandial insulin divided among meals. For patients NPO, only basal insulin with correction doses is administered (Duggan et al., 2017; Membership of the Working Party et al., 2021).

3. Timing of Transition: Subcutaneous basal insulin should be administered 2-4 hours before discontinuing intravenous insulin to ensure adequate plasma insulin levels (Umpierrez et al., 2012).

4. Patient-Specific Factors: Insulin requirements may decrease postoperatively due to improved insulin sensitivity following resolution of surgical stress, necessitating dose reduction to prevent hypoglycemia (Duggan et al., 2017).

Resuming Home Regimen

Resumption of the patient's home diabetes regimen depends on:

1. Oral Intake: Patients should resume prandial insulin or oral agents only when consistently consuming at least 50% of offered meals (Duggan et al., 2017).

2. Renal Function: Metformin should be restarted only when renal function returns to baseline and the patient is eating reliably (Membership of the Working Party et al., 2021).

3. SGLT-2 Inhibitors: These should be restarted only when the patient is eating normally, hemodynamically stable, and at low risk for hypovolemia or recurrent surgical intervention (Thiruvenkatarajan et al., 2019).

4. Insulin Pumps: These can be restarted when the patient is stable, alert, and able to manage the device independently (Nassar et al., 2022).

Special Considerations

Enteral and Parenteral Nutrition

For patients requiring enteral nutrition, regular monitoring of blood glucose is essential. Continuous enteral feeding typically requires basal insulin with regular correction doses, while bolus feeding may be managed with a combination of basal and prandial insulin (Elia et al., 2005; McMahon et al., 2012).

Parenteral nutrition presents unique challenges due to high glucose content. Current evidence supports adding regular insulin directly to the parenteral nutrition solution while maintaining a separate subcutaneous basal insulin regimen (McMahon et al., 2012).

Steroid-Induced Hyperglycemia

Glucocorticoids significantly impact glycemic control, primarily causing postprandial hyperglycemia. For patients receiving high-dose steroids, anticipatory insulin adjustment is necessary:

1. Short-Term Steroids: Additional prandial insulin coverage with dose increases of 20-40% is typically required (Duggan et al., 2017).

2. Long-Term Steroids: Addition of NPH insulin timed to coincide with peak steroid effect can be effective (Radhakutty & Burt, 2018).

3. Tapering Regimens: Insulin doses should be proactively reduced as steroid doses decrease to prevent hypoglycemia (Radhakutty & Burt, 2018).

Outpatient Surgery

For ambulatory procedures, emphasis is placed on maintaining the patient's usual regimen with minimal disruption:

1. Type 1 Diabetes: Basal insulin should be continued at 80% of the usual dose, with frequent monitoring during and after the procedure (Nassar et al., 2022).

2. Type 2 Diabetes: Oral agents may be held on the day of surgery and resumed when eating normally. For insulin-treated patients, a 20-25% reduction in basal insulin is recommended (Membership of the Working Party et al., 2021).

3. Discharge Criteria: Stable blood glucose (<14 mmol/L or <250 mg/dL) and ability to resume self-management are essential before discharge (ADA, 2024; Membership of the Working Party et al., 2021).

Emerging Technologies and Future Directions

Continuous Glucose Monitoring

The perioperative use of CGM is expanding, with evidence suggesting improved glycemic control and reduced hypoglycemia in surgical patients (Galindo et al., 2020). Factory-calibrated CGM systems have demonstrated acceptable accuracy in hospitalized patients, including those undergoing surgery (Umpierrez & Klonoff, 2018). Integration of CGM with electronic health records and clinical decision support systems represents an area of active investigation (Spanakis et al., 2016).

Automated Insulin Delivery Systems

Closed-loop insulin delivery systems have demonstrated safety and efficacy in small perioperative studies, particularly for ambulatory procedures (Umpierrez & Klonoff, 2018). These systems may provide superior glycemic control compared to conventional approaches, though larger trials are needed before widespread implementation (Bally et al., 2018).

Pharmacological Advances

Novel agents for inpatient glucose management are under investigation:

1. Long-Acting GLP-1 Receptor Agonists: These show promise for inpatient use with potential benefits including reduced insulin requirements and decreased glycemic variability (Pasquel et al., 2020).

2. Ultra-Long-Acting Insulins: Degludec and other ultra-long-acting insulins may provide more stable glycemic control with reduced hypoglycemia risk, though perioperative data remains limited (Umpierrez et al., 2018).

3. Biosimilar Insulins: These offer cost-effective alternatives for perioperative management, with comparable efficacy and safety profiles to reference products (Duggan et al., 2017).

Implementation Strategies

Standardized Protocols

Institutional protocols for perioperative diabetes management have been shown to improve outcomes:

1. Preoperative Checklists: Standardized protocols ensure appropriate medication adjustments and preoperative evaluation (Hommel et al., 2017).

2. Electronic Order Sets: These facilitate guideline-concordant care and reduce practice variation (Spanakis et al., 2016).

3. Multimodal Interventions: Combining provider education, clinical decision support, and audit-feedback mechanisms has demonstrated superior outcomes compared to single interventions (Hommel et al., 2017).

Multidisciplinary Approach

Optimal perioperative diabetes management requires collaboration among surgeons, anesthesiologists, endocrinologists, nurses, and diabetes educators:

1. Preoperative Diabetes Clinics: Dedicated clinics for preoperative optimization improve glycemic control and reduce complications (Membership of the Working Party et al., 2021).

2. Inpatient Diabetes Teams: Specialized teams reduce length of stay, readmission rates, and perioperative complications (Umpierrez et al., 2012).

3. Standardized Handoff Protocols: These ensure continuity of diabetes management across transitions of care (Spanakis et al., 2016).

Conclusion

Perioperative management of diabetes mellitus requires a systematic, evidence-based approach tailored to individual patient needs. Careful preoperative assessment, appropriate medication adjustments, and individualized glycemic targets are essential components of effective management. The integration of emerging technologies, including CGM and automated insulin delivery systems, offers promising strategies to improve perioperative outcomes.

Future research should focus on optimizing glycemic targets for specific surgical populations, evaluating the impact of newer antihyperglycemic agents in the perioperative setting, and assessing the cost-effectiveness of technology-based interventions. Multidisciplinary collaboration and standardized protocols remain cornerstones of effective perioperative diabetes management.

References

Ackland, G. L., Abbott, T. E. F., Cain, D., Edwards, M. R., Sultan, P., Karmali, S. N., Fowler, A. J., Whittle, J. R., MacDonald, N. J., Reyes, A., Paredes, L. G., Stephens, R. C. M., Gutierrez Del Arroyo, A., Woldman, S., Brandner, B., Bandner, B., Sessler, D. I., & Pearse, R. M. (2019). Preoperative systemic inflammation and perioperative myocardial injury: Prospective observational multicentre cohort study of patients undergoing non-cardiac surgery. British Journal of Anaesthesia, 122(2), 180–187.

American Diabetes Association. (2024). Diabetes care in the hospital: Standards of medical care in diabetes-2024. Diabetes Care, 47(Supplement 1), S273–S284.

Bally, L., Thabit, H., Hartnell, S., Andereggen, E., Ruan, Y., Wilinska, M. E., Evans, M. L., Wertli, M. M., Coll, A. P., Stettler, C., & Hovorka, R. (2018). Closed-loop insulin delivery for glycemic control in noncritical care. New England Journal of Medicine, 379(6), 547–556.

Buchleitner, A. M., Martínez-Alonso, M., Hernández, M., Solà, I., & Mauricio, D. (2012). Perioperative glycaemic control for diabetic patients undergoing surgery. Cochrane Database of Systematic Reviews, (9), CD007315.

Duggan, E. W., Carlson, K., & Umpierrez, G. E. (2017). Perioperative hyperglycemia management: An update. Anesthesiology, 126(3), 547–560.

Elia, M., Ceriello, A., Laube, H., Sinclair, A. J., Engfer, M., & Stratton, R. J. (2005). Enteral nutritional support and use of diabetes-specific formulas for patients with diabetes: A systematic review and meta-analysis. Diabetes Care, 28(9), 2267–2279.

Frisch, A., Chandra, P., Smiley, D., Peng, L., Rizzo, M., Gatcliffe, C., Hudson, M., Mendoza, J., Johnson, R., Lin, E., & Umpierrez, G. E. (2010). Prevalence and clinical outcome of hyperglycemia in the perioperative period in noncardiac surgery. Diabetes Care, 33(8), 1783–1788.

Galindo, R. J., Migdal, A. L., Davis, G. M., Urrutia, M. A., Albury, B., Zambrano, C., Vellanki, P., Pasquel, F. J., Fayfman, M., & Umpierrez, G. E. (2020). Comparison of the FreeStyle Libre Pro Flash Continuous Glucose Monitoring (CGM) System and Point-of-Care Capillary Glucose Testing in Hospitalized Patients With Type 2 Diabetes Treated With Basal-Bolus Insulin Regimen. Diabetes Care, 43(11), 2730–2735.

Goel, A., Rosenberg, J., & Perkins, B. A. (2023). Perioperative management of diabetes technology: A narrative review. Canadian Journal of Diabetes.

Hommel, I., van Gurp, P. J., Tack, C. J., Wollersheim, H., & Hulscher, M. E. J. L. (2017). Perioperative diabetes care: Development and validation of quality indicators throughout the entire hospital care pathway. BMJ Quality & Safety, 26(4), 340–351.

International Diabetes Federation. (2021). IDF Diabetes Atlas, 10th edition.

Jones, C., Badger, S. A., & Hannon, R. (2011). The role of carbohydrate drinks in pre-operative nutrition for elective colorectal surgery. Annals of the Royal College of Surgeons of England, 93(7), 504–507.

Lanspa, M. J., Dickerson, J., Morris, A. H., Orme, J. F., Holmen, J., & Hirshberg, E. L. (2015). Coefficient of glucose variation is independently associated with mortality in critically ill patients receiving intravenous insulin. Critical Care, 19(1), 86.

Ljungqvist, O., Scott, M., & Fearon, K. C. (2018). Enhanced Recovery After Surgery: A Review. JAMA Surgery, 152(3), 292–298.

McMahon, M. M., Nystrom, E., Braunschweig, C., Miles, J., Compher, C., & American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) Board of Directors. (2012). A.S.P.E.N. clinical guidelines: Nutrition support of adult patients with hyperglycemia. Journal of Parenteral and Enteral Nutrition, 37(1), 23–36.

Membership of the Working Party, Barker, P., Creasey, P. E., Dhatariya, K., Levy, N., Lipp, A., Nathanson, M. H., Penfold, N., Watson, B., & Woodcock, T. (2021). Guidelines for the management of adult patients with diabetes undergoing surgery and elective procedures: Improving standards. Diabetic Medicine, 38(1), e14509.

Nassar, A. A., Partridge, H., & Dhatariya, K. (2022). Management of diabetes in the perioperative setting. British Journal of Hospital Medicine, 83(4), 1–10.

NICE-SUGAR Study Investigators, Finfer, S., Chittock, D. R., Su, S. Y.-S., Blair, D., Foster, D., Dhingra, V., Bellomo, R., Cook, D., Dodek, P., Henderson, W. R., Hébert, P. C., Heritier, S., Heyland, D. K., McArthur, C., McDonald, E., Mitchell, I., Myburgh, J. A., Norton, R., … Ronco, J. J. (2009). Intensive versus conventional glucose control in critically ill patients. New England Journal of Medicine, 360(13), 1283–1297.

Partridge, H., Nassar, A., & Dhatariya, K. (2021). Perioperative management of diabetes and hyperglycaemia. Current Diabetes Reports, 21(9), 36.

Pasquel, F. J., Fayfman, M., & Umpierrez, G. E. (2020). Acute dysglycemia and hospital outcomes in non-critically ill patients. Journal of Diabetes and Its Complications, 34(6), 107585.

Radhakutty, A., & Burt, M. G. (2018). Management of endocrine disease: Critical review of the evidence underlying management of glucocorticoid-induced hyperglycaemia. European Journal of Endocrinology, 179(4), R207–R218.

Shetty, S., Inzucchi, S. E., Goldberg, P. A., Cooper, D., Siegel, M. D., & Honiden, S. (2012). Adapting to the new consensus guidelines for managing hyperglycemia during critical illness: The updated Yale insulin infusion protocol. Endocrine Practice, 18(3), 363–370.

Spanakis, E. K., Shah, N., Malhotra, K., Kemmerer, T., Yeh, H.-C., & Golden, S. H. (2016). Insulin requirements in non-critically ill hospitalized patients with diabetes and steroid-induced hyperglycemia. Hospital Practice, 42(2), 23–30.

Thiruvenkatarajan, V., Meyer, E. J., Nanjappa, N., Van Wijk, R. M., & Jesudason, D. (2019). Perioperative diabetic ketoacidosis associated with sodium-glucose co-transporter-2 inhibitors: A systematic review. British Journal of Anaesthesia, 123(1), 27–36.

Umpierrez, G. E., Hellman, R., Korytkowski, M. T., Kosiborod, M., Maynard, G. A., Montori, V. M., Seley, J. J., & Van den Berghe, G. (2012). Management of hyperglycemia in hospitalized patients in non-critical care setting: An endocrine society clinical practice guideline. The Journal of Clinical Endocrinology and Metabolism, 97(1), 16–38.

Umpierrez, G. E., & Klonoff, D. C. (2018). Diabetes technology update: Use of insulin pumps and continuous glucose monitoring in the hospital. Diabetes Care, 41(8), 1579–1589.

Umpierrez, G. E., Reyes, D., Smiley, D., Hermayer, K., Khan, A., Olson, D. E., Pasquel, F., Jacobs, S., Newton, C., & Peng, L. (2018). Hospital discharge algorithm based on admission HbA1c for the management of patients with type 2 diabetes. Diabetes Care, 37(1), 2934–2939.