Management of Hyperglycemia in Diabetic Patients

During Perioperative Period

MAT-ID-2000378 – V 1.0 (08/2020)
 Outline

1. Perioperative management in DM
• Perioperative care (pre, intra, and post op)
 Nutrition
 Pharmacotherapy
 Monitoring
• Special consideration during perioperative glucose control in older adults

2. Case illustration

3. Take home message

 Comprehensive Care Pathway for Perioperative
Management of Diabetes

The time period that begins when the decision for surgery is
made until the patient is transferred to the operation room

The time which is start from the admission into the recovery area and
continues until the patient is discharged from the care of the surgeon

Primary care Pre-operative Theatre Discharge

referral assessment and recovery

Surgical Hospital Post operative

outpatients admission Care

The time period from which the patient is transferred to the operation table and
continues till the patient transferred to the post-operative recovery area

Levy, N.,et al. British Journal of Anaesthesia. (2016). 116(4), 443-447. doi:10.1093/bja/aew049
 Predictors of Stress Hyperglycemia During Surgery

Surgical Perioperative Patient factors

• More invasive procedure • GC • Degree of illness

(open vs laparoscopic)
• Parenteral/ enteral nutrition • Pre-existing state of
• Anatomic location involving IR/deficiency
thorax and abdomen • Physical inactivity
• Advanced age
• General anesthesia (vs
epidural) • Higher BMI

• Intraoperative fluids with • Higher HbA1c

>5% dextrose
• Baseline BG level on D0

Palermo NE et al. Curr Diab Rep 2016

 Recommended control of perioperative and post-operative
hyperglycemia in selected major guidelines by professional societies

Many standards for perioperative care lack a strong evidence base

Critically ill patients  iv insulin therapy

Non-critically ill SC insulin (basal, nutritional, supplemental)
Glucose control during perioperative period: 140 - <180 mg/dL
Older patients: < 200 mg/dL
Duration of intense glucose management post-op  2 days

Postponed non-urgent surgical procedure

if pre-operative BG >400/500 mg/dL

BG blood glucose, PODs postoperative days, NS not specified a “Vulnerable” elders are defined by functional and physical impairments, self-rated
health, and age, using the Vulnerable Elders-13 Survey

Lee P, Min L, Mody L. Curr Geri Rep (2014) 3:48–55

 GENERAL PRINCIPLES

• Diabetes should be well controlled prior to elective surgery.

• Avoid insulin deficiency, and anticipate increased insulin requirements.
• The patient’s diabetes care provider should be involved in the management of diabetic patient
peri-operatively.
• Patients must be given clear written instructions concerning the management of their
diabetes both pre- and post-operatively (including medication adjustments) prior to surgery.
• Patients with diabetes undergoing day-only surgery are capable of and have written
guidelines about managing their diabetes post-operatively, and they have access to
professional advice if glycemic control deteriorates
• Patients must not drive themselves to the hospital on the day of the procedure.
• These principles may need to be individually modified depending on the patient’s
circumstances.
 PREOPERATIVE MANAGEMENT

PREOPERATIVE ASSESSMENT
• Current metabolic status & glycaemic control
ELECTIVE SURGERY • Pre-existing comorbidities/ DM complications EMERGENCY SURGERY
• Types of surgery
• Risk of requiring critical care post-op

Nutrition & fasting BG monitoring Pharmacotherapy

* SC basal bolus/ * Various insulin

OAD basal + CD/ CD insulin rate iv insulin

GLYCAEMIC CONTROL 140 – 180 mg/dL

*Glycaemic target not achieved
 PREOPERATIVE PERIODE

Pre-operative evaluation
 Type of diabetes,
 Type and frequency of daily medication,
 Metabolic control preceding surgery (nutrition, fluid/ electrolyte, BG)
 Vascular status: cardiac, renal, cerebral; or presence of diabetic complications that

may adversely affect by/ during the procedure

 Type of surgery:
• emergency/ elective,
• major/ minor procedure
• Type of anaesthesia
 Length of pre- and postoperative fasting
 Identify high risk patients requiring critical care management post operatively
Duggan et al. Anethesiology 2017
 PREOPERATIVE PERIODE

1. Fasting and Nutrition

• Nutritional support (dextrose containing solutions) during fasting period/ once the patient has
at least 1 missed meal especially DMT2 patients who get long acting insulin or SU
• Prolonged fasting is avoided in patients with diabetes. (usually 6-8 hr)
• Procedure should be done at the first round to avoid prolonged fasting.
• Low carbohydrate diets  insulin dosing and improved glucose control.
• The metabolic needs for most hospitalized patients can be supported by providing 25 to 35
calories/kg/day.
• Patients undergoing bowel investigations and radiological and other imaging procedures that
involve a period of fasting or the administration of radio-contrast also undergo same
preparation regarding nutritional support and antidiabetes adjustment

Duggan et al. Anethesiology 2017

 PREOPERATIVE PERIODE

2. Preoperative glucose management: elective procedure Nutrition

Profile of random/fasting venous/capillary blood glucose level

Good glycemic control Major surgery/ Bad glycemic control

Predicted ICU post op
Prolong fasting
Minor surgery
Duration op < 4 hr
Normal oral intake in the same day Insulin iv protocol**
BG monitoring
Continue recent antidiabetic regimen every 1-4 hr
Follow regulation of antidiabetic drugs (oral and injection) H-1 & H-0*
BG monitoring every 4-6 hr during fasting
 PREOPERATIVE PERIODE

2. Preoperative glucose management: oral antidiabetic drug*

D-0 (day of surgery) D-0 (day of surgery)
Normal oral intake in the same day/ Reduced post-op oral intake; extensive
OAD D-1 surgery; HD change/ fluid shifts
minimally invasive surgery

Sulfonylureas + - -
Metformin +* +* -
Thiazolidinediones + + -
Alpha glucosidase + + -
inhibitor
GLP-1 agonists + - -
DPP-4 inhibitors + + -
SGLT2 inhibitors - - -

* Hold if use IV contrast

SU  risk of hypoglycemia; Alpha glucosidase inh  no effect during fasting; TZD  risk of fluid retention, Metformin  if renal complication happen during
surgery ~ risk of lactic acidosis, GLP-1 agonists  delay proper GI function post-op, DPP-4 inh  primarily effect after meal, minimal effect during fasting,
SGLT2 inh  risk of euglycemic DKA, dehydration
Duggan et al. Anethesiology 2017
Sudhakaran S et al. Surgery research & practice 2015
 PREOPERATIVE PERIODE

2. Preoperative glucose management: insulin therapy*

 Sc prandial insulin is stopped when the fasting state begins.

 Sc basal insulin is continued at H-1:

• In general  at the same dose
• Consider ↓ dose if previous FBG < 100 mg/dL or there are risks of hypoglycaemia
• ↓ dose ~ 20-30% according to risk of hypoglycaemia

 If patient using sc basal insulin:

• Consider nutritional parenteral iv after 4-6hr fasting or if BG level <100-140 mg/dL, example:
dextrose 5%; 10%

 BG monitoring every 4-6 hr during fasting

Duggan et al. Anethesiology 2017

Sudhakaran S et al. Surgery research & practice 2015
 PREOPERATIVE PERIODE

2. Preoperative glucose management: emergency procedure

Measure of random/fasting venous/capillary blood glucose level

Good glycemic control Bad glycemic control

DDM: NDM: Insulin iv protocol**

Continue recent antidiabetic regimen BG monitoring every 4-6 hr BG monitoring
Follow regulation of antidiabetic drugs Give insulin CD if needed*** every 1-4 hr
(oral and injection) H-1 and H-0*
BG monitoring every 4-6 hr

BG target not achieved

with CD
DDM: diagnosed DM; NDM: newly diagnosed DM; CD: correctional dose
 PREOPERATIVE PERIODE

2. Preoperative glucose management: emergency procedure

• CD*** can be applicable in non-severe hyperglycaemia (BG 180 - < 250 mg/dL) during
fasting periode
Insulin Sensitive* Insulin Resistant*
Blood Glucose Age > 70 yr, BMI > 35 kg/m2,
mg/dl (mM) GFR < 45ml/min Usual Insulin Home TDD Insulin > 80 U
No History of Diabetes Steroids > 20mg Prednisone Daily
141-180 (7.7-10) 0 2 3
181-220 (10-12.2) 2 3 4
221-260 (12.2-14.4) 3 4 5
261-300 (14.4 – 16.6) 4 6 8
301-350 (16.6-19.4) 5 8 10
351-400(>22.2) 6 10 12
>400 (>22.2) 8 12 14
*if the patient falls into more than one insulin treatment group, choose the category with the lowest correctional dose to minimize the risk of hypoglycemia.
BMI = body mass index; GFR = glomerular filtration rate; TDD = Total daily dose
 RABBIT 2 Surgery Study: Basal Bolus (Glar-Glulisine) is
Preferred Over SSI in DMT2 Undergoing General Surgery

Sliding scale regular insulin (●) Sliding scale reguler insulin (●)
Basal Bolus (Gla-Glulisine) (●) Basal Bolus (Gla-Glulisine) (●)

Glucose levels during basal –bolus vs SSI Premeal and bedtime glucose levels werehigher throughout the day
*P < 0.001, ŧP = 0.02, †P = 0.01. in the SSI group

Randomized multicentre trial, compared safety & efficacy basal-bolus insulin with glargine once daily & glulisine before meals (n=104) to sliding
scale regular insulin (SSI) four times daily (n=107) in patients T2DM undergoing general surgery
Umpierrez GE, et al. Diabetes Care. 2011Dec;34(2):256–61.
 PREOPERATIVE PERIODE

2. Preoperative glucose management: Insulin iv protocol **

INDICATION
- emergency condition
- severe hyperglycemia
- uncontrolled BG after optimation basal bolus/ basal plus CD
(start insulin iv if BG 200 mg/dL)

• Regular human insulin intravena  serum half life 7 minutes

• Initiation of insulin iv therapy

- based on current glycemic control OR
- DM1  0.5–1 U/hour
- DM2  2- 3 U/hour or higher
 Insulin IV Titration (VRIII)**

Intravenous Insulin protocol  glucose level vs changes in glucose level

Changes in If BG Increased from Previous BG Decreased from Previous BG Decreased from Previous
glucose level BG mg/dl (mM) Measurement Measurement by Less Than 30 mg/dl Measurement by Greater Than 30 mg/dl

>241 (13.4) Increase rate by 3 U/h Increase rate by 3 U/h No change in rate
211-240 (11.7-13.4) Increase rate by 2 U/h Increase rate by 2 U/h No change in rate
181-210 (10-11.7) Increase rate by 1 U/h Increase rate by 1 U/h No change in rate
141-180 (7.8-10) No change in rate Decrease rate by ½ U/h No change in rate
110-140 (6.1-7.8) No change in rate Old insulin infusion
100-109 (5.5-6.1) 1. Hold insulin infusion
Glucose 2. 2. Recheck BG hourly
level 3. Restart infusion at ½ the previous infusion rate if BG > 180 mg/dl ( 10mM)
71-99 (3.9-5.5) 1. Hold insulin infusion
2. Check BG every 30 minutes until BG > 100mg/dl (5.5mM)
3. Resume BG checks every hour
4. Restart infusion at ½ the previous infusion rate if BG > 180mg/dl ( 10mM)
70 (3.9) or lower If BG = 50-70 (2.8-3.9mM),
4. Give 25 ml D50
5. Repeat BG checks every 30 min until BG > 100 mg/dl (5.5mM)
If BG = 50-70 (2.8mM),
6. Give 50 ml D50
7. Repeat BG every 15 min until > 70 mg/dl (3.9mM)
Human Resource ! 8. When BG > 70mg/dl, check BG every 30 min until > 100mg/dl (5.5mM). Repeat 50 ml D50
dose if BG < 50mg/dl a second time and start D10 infusion
9. After BG > 100mg/dl (5.5mM), resume hourly BG xheck
Restart infusion at ½ the previous infusion rate if BG > 180mg/dl (10mM)
 INTRAOPERATIVE PERIODE

1. BG monitoring
• 2-4 hr : elective, minor surgery, good glycemic control
• 1-2 hr : emergency, major surgery, bad glycemic control

2. Good glycaemic control  no need of CD

3. Bad glycemic control

• On iv insulin : titration based on changes of BG**
• Not on iv insulin
 - BG < 300 mg/dL : give CD***
 - BG 300 mg/dL : insulin iv protocol
 POSTOPERATIVE PERIODE

1. Categorize the patients whether they are

• Critically ill vs non critically ill
• Poor or good oral intake

2. Critically ill  IV insulin protocol is continued

Non critically ill  prefer SC route

3. Poor vs good oral intake

• Poor intake  maintain glucose infusion
• Good nutritional intake  stop glucose infusion after meal and resume antidiabetic
agent (oral/insulin)

4. Frequent BG monitoring depend on patient’s condition

Diabetes management expertise must be available for the post-operative

management of glycemic instability.
 Insulin Therapy Among
Insulin TherapyHospitalized Non-Critically Ill
in Non Critical Setting
Patients With DM
Patient Basal Insulin Needs Nutritional/Prandial Insulin Supplemental Dose Insulin
Status Needs Needs
Eating meals • Intermediate acting insulin BID • Regular insulin • Regular or rapid acting insulin
or at bedtime (SC) • Rapid acting insulin analog before meals and/or at bedtime
• Long acting insulin analog OD as needed
(SC)
• Insulin infusion (IV) BASAL BOLUS INSULIN

Not eating • Intermediate acting insulin BID Not applicable • Regular insulin every 4-6 h
meals or at bedtime (SC) • Rapid acting insulin analog
(parenteral • Long acting insulin analog OD every 4 h
nutrition) (SC)
• Insulin infusion (IV) BASAL PLUS CORRECTIONAL DOSE INSULIN

Enteral tube • Intermediate acting insulin in the • Regular insulin every 4-6 h • Regular insulin every 4-6 h
feeding morning or BID (SC) • Rapid acting insulin analog • Rapid acting insulin analog
• Long acting insulin analog at every 4 h every 4 h
bedtime or in the morning (SC) (depend on the schedule)
• Insulin infusion (IV) BASAL BOLUS INSULIN

Clement et al. Diabetes Care 2004; 27(2): 553-591

 POSTOPERATIVE INSULIN THERAPY PROTOCOL
Non-critically ill: NPO/poor oral intake
Total Daily Dose
Insulin Resistant
Total Daily Dose BMI > 35 kg/m2,
Insulin Sensitive Total Daily Dose Steroids > 20 mg
Type of Insulin Age > 70 yr, GFR < 45 ml/min Insulin Usual Prednisone Daily

NPO/Poor oral Intake / Clear Basal (glargine/detemir) 0.1-0.15 U •kg-1 •day-1 0.2-0.25 U •kg-1 •day-1 0.2-0.25 U •kg-1 •day-1
liquid Diet
USE BASAL PLUS REGIMEN Correctional (rapid acting) Treat BG > 180 mg/dl (10mM) using correctional calculation or table 5

Insulin Sensitive* Insulin Resistant*

Age > 70 yr, BMI > 35 kg/m2
Blood Glucose GFR < 45 ml/min, Usual Home TDD Insulin > 80 U
mg/dl (mM) No History of Diabetes Insulin Steroids > 20mg Prednisone Daily

141-180 (7.7-10) 0 2 3
Corr dose can be calculated 
181-220 (10-12,2) 2 3 4
- (BG - 100)/insulin sensitivity factor.
221-260 (12.2-14.4) 3 4 5
Insulin sensitivity factor 1,800/patient’s
261-300 (14.4-16.6) 4 6 8
TDD of insulin
301-350 (16.6-19.4) 5 8 10
….. OR…… ”40” for pts w oral drug at home
351-400 (19.4-22.2) 6 10 12
>400 (>22.2) 8 12 14

*If the patients fall into more than one insulin treatment group, choose the category with the lowest correctional dose to
minimize the risk of hypoglycemia, BMI = body mass index; GFR = glomerular filtration rate; TDD = total daily dose.
 POSTOPERATIVE INSULIN THERAPY PROTOCOL
Non-critically ill: Normal Oral Intake
Total Daily Dose
Insulin Resistant
Total Daily Dose BMI > 35 KG/M2,
Insulin Sensitive * Total Daily Dose Steroids > 20 mg
Type of Insulin Age > 70yr, GFR < 45ml/min Insulin Usual Prednisone Daily

Normal Oral Intake At Meals Basal (glargine/detemir)

0.1-0.15 U• kg-1 • day-1 0.2-0.25 U• kg-1 • day-1 0.35 U• kg-1 • day-1
USE BASAL BOLUS Prandial (rapid acting)
0.1-0.15 U• kg-1 • day-1 0.2-0.25 U• kg-1 • day-1 0.35 U• kg-1 • day-1
REGIMEN Orrectional (rapid acting) Treat BG > 180 mg/dl (10mM) using correctional calculation or table 5

*If the patients fall into more than one insulin treatment group, choose the category with the lowest insulin dose to minimize the risk
of hypoglycemia, BG – Blood Glucose; BMI = body mass index; GFR = glomerular filtration rate; NPO = nothing by mouth
 Hypoglycemia and Perioperative Complications

• Unmanaged hypoglycemia  neurological complications including somnolence,

unconsciousness, and seizures  irreversible neurological or death

• Hypoglycemia enhances morbidity/mortality in critically ill diabetic patients and can

prolong ICU/hospital stay

Overall, with the use of careful glucose management strategies,

the primary outcome measures of surgery are similar between
diabetic and nondiabetic patients

Vaan den boom. Diabetes Care 2018

Duggan et al. Anesthesiology 2017
 CASE ILLUSTRATION

CASE 1

CASE 2
• Male, 40 yo
• T2DM 2 y, th metformin 500 BID • Male, 40 yo
• BMI 26 kg/m2, hypo (-) • No history of DM, fever 3 d, abdominal pain,
• Stroke (-), ACS (-) vomit, BMI 22 kg/m2
• HT (-), dyslipidaemia (+) • Dx acute peritonitis ec app perforation
• A1c 7%, eGFR 90 • GCS 14, T 39C, BP 140/90 mmHg
• Elective lap-chole • BG 480 mg/dL; b(OH) 1,5; HCO3 11
• eGFR 60; Na/K/Cl 145/3,4/95
• Open laparotomy
 CASE ILLUSTRATION

CASE 3

• Female, 50 yo CASE 4
• T2DM 10 y, th glargine 30 u OD,
Glulisine 8 TID, metformin 500 TID • Female, 45 yo
• BMI 27 kg/m2, hypo (+) • DM 5 y, Th gliclazide MR OD,
• Stroke (-), ACS (-), HT (+), sitagliptin-metformin 50/500 BID
dyslipidaemia (+)
• A1c 8,7; FBG 180/ RBG 290 mg/dL
• A1c 7,4%, eGFR 80, FBG 120 mg/dL
• Stroke (-), HT (-)
• Dx uterine myoma
• Dx left kidney tumor
• Elective laparotomy myomectomy
• Open laparotomy-
• Elective left nefrectomy
 How To Prepare Perioperative Period?

CASE 1
• •CASE 1
Male, 40 yo
• T2DM 2 y, th metformin 500 BID
Preoperative Assessment
• BMI 26 kg/m , hypo (-)
2

• Stroke (-), ACS (-)

• Recent glycemic control  good
• HT (-), dyslipidaemia (+)
• Chronic complication  No
• A1c 7%, eGFR 90
• Elective lap-chole • Type of surgery  elective, major surgery
• Predicted high care post-op? No
• Prolonged fasting post op? maybe yes
(collaboration between internist and surgeon)
 How To Prepare Perioperative Period?

CASE 1
• •CASE 1
Male, 40 yo
• T2DM 2 y, th metformin 500 BID
Preoperative Management
• BMI 26 kg/m , hypo (-)
2

• Stroke (-), ACS (-)

• Fasting 6 hr pre-op
• HT (-), dyslipidaemia (+)
• Metformin is stopped when fasting begin
• A1c 7%, eGFR 90
• Elective lap-chole • Monitor BG every 4 hr during fasting (100-<180 mg/dL)
• IV nutrition is not given routinely, except BG < 100
• If BG 180 - < 250  start CD
• If BG 250  start iv insulin protocol
 How To Prepare Perioperative Period?

CASE 1
• •CASE 1
Male, 40 yo
• T2DM 2 y, th metformin 500 BID
Intra Operative Management
• BMI 26 kg/m , hypo (-)
2

• Stroke (-), ACS (-) • Monitor BG intra op

• HT (-), dyslipidaemia (+)
 1-2 hr in on iv insulin
• A1c 7%, eGFR 90
 4 hr if BG well controlled w/wo CD
• Elective lap-chole
• IV nutrition is not given routinely, except BG < 100
• If BG 180 - < 250  start CD
• If BG 250  start iv insulin protocol
 How To Prepare Perioperative Period?

CASE 1
• •CASE 1
Male, 40 yo
• T2DM 2 y, th metformin 500 BID
Post Operative Management
• BMI 26 kg/m , hypo (-)
2

• Stroke (-), ACS (-) • Nutrition planning

• HT (-), dyslipidaemia (+)
• Monitor BG post op ~ nutrition
• A1c 7%, eGFR 90
 BG daily curve if start eating at the same day
• Elective lap-chole
• Metformin is given when oral intake begin
 How To Prepare Perioperative Period?

CASE 2
• •CASE 1
Male, 40 yo
• No history of DM, fever 3 d,
abdominal pain, vomit, BMI 22 kg/m2 Pre Operative Assessment
• Dx acute peritonitis ec app
perforation
• GCS 14, T 39C, BP 140/90 mmHg • Recent glycemic control  bad
• BG 480 mg/dL; b(OH) 1,5; HCO3 11
• Chronic complication  No
• eGFR 60; Na/K/Cl 145/3,4/95
• Open laparotomy • Type of surgery  emergency, major surgery
• Predicted high care post-op? Yes
• Prolonged fasting post op? Yes
 How To Prepare Perioperative Period?

CASE 2
• •CASE 1
Male, 40 yo
• No history of DM, fever 3 d,
abdominal pain, vomit, BMI 22 kg/m2 Pre Operative Management
• Dx acute peritonitis ec app
perforation
• GCS 14, T 39C, BP 140/90 mmHg
• Fasting 6 hr pre-op
• BG 480 mg/dL; b(OH) 1,5; HCO3 11 • IV insulin therapy protocol (DKA)
• eGFR 60; Na/K/Cl 145/3,4/95
• Open laparotomy • Monitor BG every 1-2 hr
• Target DKA resolved if possible
 How To Prepare Perioperative Period?

CASE 2
• •CASE 1
Male, 40 yo
• No history of DM, fever 3 d,
abdominal pain, vomit, BMI 22 kg/m2 Intra Operative Management
• Dx acute peritonitis ec app
perforation
• IV insulin therapy protocol
• GCS 14, T 39C, BP 140/90 mmHg
• BG 480 mg/dL; b(OH) 1,5; HCO3 11 • Monitor BG every 1-2 hr
• eGFR 60; Na/K/Cl 145/3,4/95
• Open laparotomy • IV nutrition is given when BG < 200 mg/dL
 How To Prepare Perioperative Period?

CASE 2
• •CASE 1
Male, 40 yo
• No history of DM, fever 3 d,
abdominal pain, vomit, BMI 22 kg/m2 Post Operative Management
• Dx acute peritonitis ec app
perforation
• GCS 14, T 39C, BP 140/90 mmHg • High care unit
• BG 480 mg/dL; b(OH) 1,5; HCO3 11 • Nutrition planning
• eGFR 60; Na/K/Cl 145/3,4/95
• Open laparotomy • IV insulin therapy protocol
• Monitor BG every 1-2 hr
• BG target 140 – 180 mg/dL
 How To Prepare Perioperative Period?

CASE 3
• •CASE 1 yo
Female, 50
• T2DM 10 y, th glargine 30 u OD,
Glulisine 8 TID, metformin 500 TID Pre Operative Assessment
• BMI 27 kg/m2, hypo (+)
• Stroke (-), ACS (-), HT (+),
dyslipidaemia (+) • Recent glycemic control  good
• A1c 7,4%, eGFR 80, FBG 120 • Chronic complication  No
mg/dL
• Dx uterine myoma • Type of surgery  elective, major surgery
• Elective laparotomy myomectomy
• Predicted high care post-op? No
• Prolonged fasting post op? No
 How To Prepare Perioperative Period?

CASE 3 Pre Operative Management

• •CASE 1yo
Female, 50
• Fasting 6 hr pre-op
• T2DM 10 y, th glargine 30 u OD,
Glulisine 8 TID, metformin 500 TID • Glargine is given H-1 (pm) full dose; H-0 (am)
• BMI 27 kg/m2, hypo (+)
• Stroke (-), ACS (-), HT (+),
80% dose
dyslipidaemia (+) • Glulisine and Metformin is stopped when fasting
• A1c 7,4%, eGFR 80, FBG 120 mg/dL
• Dx uterine myoma
begin
• Elective laparotomy myomectomy • Monitor BG every 4 hr during fasting (100-<180
mg/dL)
• IV nutrition is given start at 4-6 hr after fasting or if
BG < 100 mg/dL
• If BG 180 - < 250  start CD
• If BG 250  start iv insulin protocol
 How To Prepare Perioperative Period?

CASE 3
• •CASE 1 yo
Female, 50
• T2DM 10 y, th glargine 30 u OD,
Glulisine 8 TID, metformin 500 TID Intra operative management
• BMI 27 kg/m2, hypo (+)
• Stroke (-), ACS (-), HT (+),
dyslipidaemia (+)
• Monitor BG intra op
• A1c 7,4%, eGFR 80, FBG 120  1-2 hr in on iv insulin
mg/dL
 4 hr if BG well controlled w/wo CD
• Dx uterine myoma
• Elective laparotomy myomectomy • IV nutrition is continued
• If BG 180 - < 250  start CD
• If BG 250  start iv insulin protocol
 How To Prepare Perioperative Period?

CASE 3
• •CASE 1 yo
Female, 50
• T2DM 10 y, th glargine 30 u OD,
Glulisine 8 TID, metformin 500 TID Post operative management
• BMI 27 kg/m2, hypo (+)
• Stroke (-), ACS (-), HT (+),
dyslipidaemia (+) • Nutrition planning
• A1c 7,4%, eGFR 80, FBG 120 • Monitor BG post op ~ nutrition
mg/dL
• Dx uterine myoma  BG daily curve if start eating at the same day
• Elective laparotomy myomectomy  Insulin sc titration based on BG daily curve
• Glulisine and metformin is given when oral intake
begin, if there is possibility of decreased oral
intake  adjust glulisine dose
• Glargine is given according to pre-op schedule
 How To Prepare Perioperative Period?

CASE 4
• •CASE 1yo
Female, 45
• DM 5 y, Th gliclazide MR OD,
sitagliptin-metformin 50/500 BID Pre Operative Assessment
• A1c 8,7; FBG 180/ RBG 290 mg/dL
• Stroke (-), HT (-) • Recent glycemic control  bad
• Dx left kidney tumor
• Open laparotomy • Chronic complication  No
• Elective left nefrectomy • Type of surgery  elective, major surgery
• Predicted high care post-op? No
• Prolonged fasting post op? No
 How To Prepare Perioperative Period?

CASE 4
• •CASE 1yo
Female, 45 Pre Operative management
• DM 5 y, Th gliclazide MR OD,
sitagliptin-metformin 50/500 BID • Fasting 6 hr pre-op
• A1c 8,7; FBG 180/ RBG 290 mg/dL
• Stroke (-), HT (-) • Gliclazide, sita-metf are given H-1
• Dx left kidney tumor • Gliclazide and sita-metf are stopped at H0
• Open laparotomy
• Elective left nefrectomy • Monitor BG every 4 hr during fasting (100-<180
mg/dL)
• IV nutrition is given start at 4-6 hr after fasting or
if BG < 100 mg/dL
• If BG 180 - < 250  start CD
• If BG 250  start iv insulin protocol
 How To Prepare Perioperative Period?

CASE 4
• •CASE 1yo
Female, 45
• DM 5 y, Th gliclazide MR OD,
sitagliptin-metformin 50/500 BID Intra operative management
• A1c 8,7; FBG 180/ RBG 290 mg/dL
• Stroke (-), HT (-) • Monitor BG intra op
• Dx left kidney tumor
 1-2 hr in on iv insulin
• Open laparotomy
• Elective left nefrectomy  4 hr if BG well controlled w/wo CD
• IV nutrition is continued
• If BG 180 - < 250  start CD
• If BG 250  start iv insulin protocol
 How To Prepare Perioperative Period?

CASE 4
• •CASE 1yo
Female, 45
• DM 5 y, Th gliclazide MR OD,
sitagliptin-metformin 50/500 BID Post operative management
• A1c 8,7; FBG 180/ RBG 290 mg/dL
• Stroke (-), HT (-) • Nutrition planning
• Dx left kidney tumor
• Open laparotomy • Monitor BG post op ~ nutrition
• Elective left nefrectomy  BG daily curve if start eating at the same day
• Gliclazide and sita-metf are given when oral intake
begin and post-op BG < 180 mg/dL
• If post-op BG 180 mg/dL  basal bolus/ basal +
CD sc insulin therapy
 TAKE HOME MESSAGE

• Perioperative hyperglycemia gives serious comorbidities

• BG target during perioperative is less than 180-200 (elderly) mg/dL

• PERIOPERATIVE  preoperative, intraoperative, and postoperative

• Preoperative  assessment current condition and the risk of complications during and post-
operative; preparation include nutrition, duration of fasting and BG management

• Postoperative  re-assessment patient status (critically-ill or noncritically-ill; intake status)

• Need collaboration between consultant (specialist, include anesthesiologist), GP, and nurse