Clinical Guideline Diabetes management during surgery (adults) Standard 8 of the National Service Framework for Diabetes states that all children, young people and adults with diabetes admitted to hospital, for whatever reason, will receive effective care of their diabetes. Wherever possible they will continue to be involved in decisions concerning the management of their diabetes. National guidance entitled Day Surgery and the Diabetic patient states: the aim is to manage the diabetes according to safe and simple protocols. This guideline aims to enhance the care provided to patients with diabetes during surgery. It applies to all surgical patients with type 1 or type 2 diabetes who are controlled on oral anti-diabetic medication and/or insulin. It is split into those undergoing morning procedures and those undergoing afternoon procedures. The purpose of this guideline is to: Give practical advice to clinical staff on how to manage patients with diabetes who are undergoing surgery. Ensure that patients with diabetes maintain effective glycaemic control and minimise hypoglycaemic events during admission. Preoperative diabetic control Ideally all patients should have their diabetes well controlled and should have a glycosylated haemoglobin (HbA1c) level of less than 7.5 (this is measured during pre-op assessment). A HbA1c of between 7.5 and 9.0 suggests inadequate control of diabetes. A HbA1c above 9.0 indicates poor control of diabetes. The decision to operate or postpone a routine operation in a poorly controlled diabetic should be taken jointly by surgeons and anaesthetists taking into consideration other comorbidities and patient-specific factors and by assessing the risks / benefits involved. On the day of surgery a preoperative blood glucose level should be checked and documented. A level of 4 12 mmol/l is acceptable although, ideally, it should be between 6 10mmol/L. If the patient s blood sugar is above 12 mmol/l, the anaesthetist or the surgical team should be informed so that further management (eg, a glucose/potassium/insulin [GKI] infusion) can be considered (see page 5). Patients with diabetes should be operated first on the list (whether in the morning or afternoon) so that there is minimal disruption of their diet and medication. Page 1 of 5
Morning procedures 1. Patients on oral antidiabetic medicines (eg, metformin, gliclazide) and/or longacting insulin (eg Lantus, Levemir ) Oral antidiabetic medicines and long-acting insulins should be taken as normal Withhold oral antidiabetic medication. Continue long-acting insulin (if due on the morning of procedure). Oral antidiabetic medicines can be taken after the operation once the patient has had their first meal (ie, the morning dose should be taken after lunch). 2. Patients on twice-a-day insulin regimen: (eg: Novomix 30, Humalog Mix 25 ) Omit morning insulin dose Administer half the morning dose of insulin after the patient has eaten lunch (this is to avoid hypoglycaemia as the patient may not prefer to have a normal meal and to ensure that the patient does not vomit or refuse meal) If the procedure is delayed beyond midday, consider starting a GKI infusion (see page 6). Page 2 of 5
3. Patients on four-times-a-day insulin regime (ie: basal-bolus) Omit morning insulin dose of short-acting insulin (eg, Humalog, Novorapid, Apidra or Actrapid ). Continue the same dose of long-acting insulin (whether taken the night before or on the morning of the procedure) Administer half the morning dose of short-acting insulin after patient has eaten lunch (this is to avoid hypoglycaemia as the patient may not prefer to have a normal meal and to ensure that the patient does not vomit or refuse meal) If the procedure is delayed beyond midday, consider starting a GKI infusion (see page 6). Afternoon procedures 1. Patients on oral antidiabetic medicines (eg, metformin, gliclazide) and/or longacting insulin (eg Lantus, Levemir ) Oral antidiabetic medicines and long-acting insulins should be taken as normal Oral antidiabetic medicines should be taken as normal provided the patient eats a light breakfast (otherwise, the dose should be omitted) Continue long-acting insulin (if due on the morning of procedure). Lunchtime on the day of the procedure: Omit lunchtime dose of oral antidiabetic medicines Oral antidiabetic medicines can be taken after the operation once the patient has had their first meal (ie, the evening dose should be taken after an evening meal). Page 3 of 5
2. Patients on twice-a-day insulin regimen: (eg: Novomix 30, Humalog Mix 25 ) Administer half the usual morning insulin dose with breakfast Administer half the evening dose of insulin after the patient has eaten an evening meal (this is to avoid hypoglycaemia as the patient may not prefer to have a normal meal and to ensure that the patient does not vomit or refuse meal) 3. Patients on four-times-a-day insulin regime (ie: basal-bolus) Administer the normal morning insulin dose of short-acting insulin (eg, Humalog, Novorapid, Apidra or Actrapid ) provided the patient eats a light breakfast Continue the same dose of long-acting insulin (whether taken the night before or on the morning of the procedure) Lunchtime on the day of the procedure: Omit lunchtime dose of short-acting insulin Administer half the normal dose of short-acting insulin after the patient has eaten their first meal after the procedure (this is to avoid hypoglycaemia as the patient may not prefer to have a normal meal and to ensure that the patient does not vomit or refuse meal) Page 4 of 5
GKI infusions A GKI infusion can be considered during the perioperative period for: Patients with uncontrolled or poorly controlled diabetes (as determined by HbA1c) Patients with type 1 diabetes who are undergoing major surgery Patients who might not be able to start eating normally within 4 hours after surgery The standard GKI regimen: 500mL dextrose 10% with 10mmol potassium chloride and 10units of Actrapid insulin to run at 100mL/hr. The insulin concentration should be varied according to blood glucose levels. In special circumstances (eg, patients with heart failure or those with renal failure who require fluid restriction), a 20% dextrose solution with 20units of insulin with or without potassium chloride, running at 50mL/hr, can be used instead. Please consult the anaesthetist or the surgical team members if there are any doubts or concerns regarding the management of surgical patients with diabetes. Requirements for discharge If the patient has type 1 diabetes, ensure he or she has a blood glucose <15mmol/L before being discharged. For further advice If in doubt, contact the diabetes specialist nurses on ext 2130 (Arrowe Park), ext 4332 (Clatterbridge) or bleep the nurses at either site. References Department of Health (England). National Service Framework for Diabetes: standards. December 2001. Available at: www.dh.gov.uk (accessed 6 December 2010). British Association of Day Surgery. Day surgery & the diabetic patient: Guidelines for the assessment and management of diabetes in day surgery patients. Colman Print: Norwich; September 2004. Page 5 of 5