Singapore General Hospital

Supporting Documents

Title: Document No: Page 1 of 10

Guidelines on Preoperative Assessment of Diabetes 75400-SD-007
Mellitus
Issuing Department: Preoperative Evaluation Clinic Approved By:
Date Revised: 27 July 2018 A/Prof Soh Chai Rick
Version Number: 4 Head,
Issued by: Dr Hairil Rizal Abdullah, Department of Anesthesiology
Clinical Director, Perioperative Services Singapore General Hospital

INTRODUCTION

Diabetic patients can be broadly classified into Type 1 and Type 2 Diabetes Mellitus. Optimal blood
glucose control of the diabetic patient is of particular importance peri-operatively due to alterations in
calorie intake and increased stress on the body throughout a surgical procedure. Certain types of
gastrointestinal surgery will further increase complications particularly if they impact on long-term
nutrition of the patient. As such, it is important that a thorough evaluation and appropriate
management of the diabetic patient be conducted to ensure the safety of proceeding with surgery.

ASSESSMENT

1. History

 Elicit range of sugar level from patient based on home monitoring

 Obtain diabetic medication history from patient (OHGA and insulin dose, frequency)

 Check patient’s compliance to medications and lifestyle changes, recent hospital stays or
changes in DM meds (suggestive of worsening control)

 Screening of organs – CVS (silent CHD, arrhythmia), CRF with raised creatinine, CNS
(stroke or TIA), autonomic neuropathy (gastroparesis and orthostatic hypotension)

2. Physical Examination

 Airway assessment – limited mouth opening due to TM joint and limited neck movement
(glycosylation of neck soft tissue)

 Screening of organs as above

3. Investigations

 U/E/Creat/Glucose

 HbA1c if not previously done, urine dipstick for ketones if indicated

 Singapore General Hospital

Supporting Documents

Title: Document No: Page 2 of 10

Guidelines on Preoperative Assessment of Diabetes 75400-SD-007
Mellitus
Issuing Department: Preoperative Evaluation Clinic Approved By:
Date Revised: 27 July 2018 A/Prof Soh Chai Rick
Version Number: 4 Head,
Issued by: Dr Hairil Rizal Abdullah, Department of Anesthesiology
Clinical Director, Perioperative Services Singapore General Hospital

PREOPERATIVE MANAGEMENT

1. Pre-operative medication guidelines

Diabetic Medication Day before Surgery Day of Surgery

OHGAs Full dose Omit

Incretins Full dose Omit

SGLT2-i Omit Omit

Insulin therapy - To refer to the table below

 For patients on SGLT2i, to routinely check for blood glucose and ketone level if
developed symptoms or having poor oral intake / dehydrated postoperatively.
SGLT2i and metformin should only be restarted once full feeds are
established.
 Singapore General Hospital

Supporting Documents

Title: Document No: Page 3 of 10

Guidelines on Preoperative Assessment of Diabetes 75400-SD-007
Mellitus
Issuing Department: Preoperative Evaluation Clinic Approved By:
Date Revised: 27 July 2018 A/Prof Soh Chai Rick
Version Number: 4 Head,
Issued by: Dr Hairil Rizal Abdullah, Department of Anesthesiology
Clinical Director, Perioperative Services Singapore General Hospital

2. Blood Glucose Action Plan

Management of pre-operative blood glucose level – aim target of less than 11 mmol/L

BG level (mmol/L) Action

12-15  Advise continued glucose monitoring by outpatient clinics,

such as polyclinic or general practitioners (OPS/GP)

15-20  Refer Internal medicine Perioperative Team (IPT) for

glucose control, with a Fasting Blood Glucose level and
HbA1c

 To discuss with surgical team, suggest postpone surgery

for at least 1 week for glucose control, or 2 weeks if there
is organ involvement (for further investigations)

> 20  Emergency!

 Need to rule out Diabetic Keto Acidosis (DKA) or

Hyperosmolar Hyperglycemic State (HHS). Diagnostic
criteria:

DKA HHS
Glucose > 14mmol/L Glucose > 33 mmol/L
AND AND
HCO3 < 18mmol/L Effective serum osmolality
AND > 320mOsm/L
Serum Ketone >1 or urine
ketone >2+

 If DKA or HHS present, to admit via Accident and

Emergency department

 If no DKA or HHS, to call IPT (same as for blood glucose

15-20)

 To discuss with surgical team, suggest postpone surgery

for at least 1 week for glucose control, or 2 weeks if there
is organ involvement (for further investigations)
 Singapore General Hospital

Supporting Documents

Title: Document No: Page 4 of 10

Guidelines on Preoperative Assessment of Diabetes 75400-SD-007
Mellitus
Issuing Department: Preoperative Evaluation Clinic Approved By:
Date Revised: 27 July 2018 A/Prof Soh Chai Rick
Version Number: 4 Head,
Issued by: Dr Hairil Rizal Abdullah, Department of Anesthesiology
Clinical Director, Perioperative Services Singapore General Hospital

3. For Patients on insulin

 Patients must not drive themselves to the hospital on the day of the procedure
 Patients with diabetes should be on the morning list, preferably first on the list. If not,
please call surgeon to arrange
 Patients must be given clear written instructions concerning the management of their
diabetes prior to surgery.
 If patient is going to be admitted postoperatively, to remind surgeon to arrange for IPT
review in the ward
 Order capillary blood glucose on admission to SDA and 2-hourly thereafter
 For ALL patients with type 1 diabetes, please refer to endocrinologist upon admission for
inpatient management
 Adults with type 1 diabetes and not on follow-up with any endocrinologist – to be admitted
one day prior to surgery for glycaemic control

4. Referral plans

 Urgent referral to SGH Diabetes Centre (Pls call respective endocrinologist running
clinics on that day) for Type 1 diabetes with suboptimal follow up
 Refer IPT urgent for
i. Newly diagnosed diabetes with blood glucose levels >15 mmol/L or HbA1c > 9
ii. Previously diagnosed diabetes with marked or symptomatic hyperglycaemia not
responding to current therapy (i.e. glucose levels consistently >15.0 mmol/L and
HbA1c > 9)
 non-urgent referral to IPT (waiting time for appointment varies):
i. Patients with or are at risk of recurrent severe hypoglycaemia
ii. Patients with suboptimal control by GP/OPS, but HbA1c <9%,
 For other cases eg Newly diagnosed diabetes without marked or symptomatic
hyperglycaemia or existing type 2 diabetes with suboptimal glycaemic control (HbA1c 7-
9%), to refer GP/Polyclinic
 Singapore General Hospital

Supporting Documents

Title: Document No: Page 5 of 10

Guidelines on Preoperative Assessment of Diabetes 75400-SD-007
Mellitus
Issuing Department: Preoperative Evaluation Clinic Approved By:
Date Revised: 27 July 2018 A/Prof Soh Chai Rick
Version Number: 4 Head,
Issued by: Dr Hairil Rizal Abdullah, Department of Anesthesiology
Clinical Director, Perioperative Services Singapore General Hospital

Types of Insulin

Generic Name Brand Name Type

Lispro Humalog mealtime
Soluble Human Insulin Actrapid mealtime
Aspart NovoLog Mealtime
Glulisine Apidra Mealtime
Regular Novolin R Mealtime
NPH Novolin N Basal
Insulatard
Glargine Lantus Basal
Detemir Levemir Basal
Isophane & regular Novomix combination
Mixtard
 Singapore General Hospital

Supporting Documents

Title: Document No: Page 6 of 10

Guidelines on Preoperative Assessment of Diabetes 75400-SD-007
Mellitus
Issuing Department: Preoperative Evaluation Clinic Approved By:
Date Revised: 27 July 2018 A/Prof Soh Chai Rick
Version Number: 4 Head,
Issued by: Dr Hairil Rizal Abdullah, Department of Anesthesiology
Clinical Director, Perioperative Services Singapore General Hospital

Type 2 DM Type 1 DM

Admit 1 day pre-op

HbA1c Blood Glucose
for glycaemic control

ENDOCRINE TO
HbA1c 7-9% HbA1c > 9% 12-15 15-20 > 20 REVIEW ON
ADMISSION

Document as poorly Refer IPT with

Refer IPT non-urgent Advise h/c monitoring Fasting Blood EMERGENCY!
controlled diabetes
Glucose and HbA1c

KIV Postpone surgery Rule out DKA and

Refer to IPT OPS/GP x1/52 or x2/52 if HHS, if present, admit
organ involvement via A&E

To refer IPT

Postpone surgery for

glucose optimisation

To refer to point 4 (referral plans) for actions marked with *

FIGURE 1 – Blood Sugar Action Plan

 Singapore General Hospital

Supporting Documents

Title: Document No: Page 7 of 10

Guidelines on Preoperative Assessment of Diabetes 75400-SD-007
Mellitus
Issuing Department: Preoperative Evaluation Clinic Approved By:
Date Revised: 27 July 2018 A/Prof Soh Chai Rick
Version Number: 4 Head,
Issued by: Dr Hairil Rizal Abdullah, Department of Anesthesiology
Clinical Director, Perioperative Services Singapore General Hospital

Management of hypoglycaemic agents for SAME DAY ADMISSION (Type 2 DM) patients

Medications for Type

2 DM

Insulin OHGAs

Continue normal
Long-acting / basal Mixed/combi dose pm before
surgery

Continue normal Continue normal

dose pm before dose pm before Check if patient is on
surgery surgery any SGLT-2i (eg
Empaglifozin,
Dapaglifozin,
take half of normal Canaglifozin). If they
Measure H/C on are, to stop 48 hours
dose on am of
surgery morning of surgery: prior to surgery.

if H/C ≥ 11, take half

H/C on Admission Omit other OHGAs
of normal dose
on morning of
surgery

if H/C < 11take one-

third of normal dose
H/C on admission

Re-check H/C on
Admission

SGH Nil-by-mouth (NBM) INPATIENT Glucose Management for Type 2 Diabetes Mellitus (T2DM) for Elective
Procedures

For: T2DM patients on insulin or oral glucose lowering drugs when NBM.

Excluded: T1DM, pregnancy, labour, DKA, HHS, TPN and ICU setting.

Please consult endocrinology registrar on-call if there is difficulty in controlling glucose within the target range
(4 – 10 mmol/l).
 Singapore General Hospital

Supporting Documents

Title: Document No: Page 8 of 10

Guidelines on Preoperative Assessment of Diabetes 75400-SD-007
Mellitus
Issuing Department: Preoperative Evaluation Clinic Approved By:
Date Revised: 27 July 2018 A/Prof Soh Chai Rick
Version Number: 4 Head,
Issued by: Dr Hairil Rizal Abdullah, Department of Anesthesiology
Clinical Director, Perioperative Services Singapore General Hospital

Insulin-treated Non-insulin treated

Continue usual dose of Basal insulin If only short duration of fasting is expected (i.e. miss 1 meal)
(Glargine, Detemir, Insulatard)
Omit oral glucose lowering drugs.
For Mixtard or Novomix: calculate 70% as basal
If prolonged fasting is expected (i.e. miss ≥ 2 meals) :
requirement**
Start Basal insulin (insulatard) based on 0.1 units/kg in the morning
E.g. Mixtard 40 units pre Breakfast.
of the procedure.
Basal insulin = 40x0.7=28 units
E.g. 50 years old man, with body weight of 60 kg who is
Plan: Prescribe insulatard 28 units to be administered
on metformin + glipizide.
in the morning of the procedure.
Fasting capillary glucose is 12 mmol/l in the morning of
Start dextrose 5% intravenously.
procedure.
Prescribe supplemental insulin as below.
Basal insulin requirement = 0.1 X 60 = 6 units

Plan: Stop metformin and glipizide.

**Note: When NBM, the basal component can be
Prescribe insulatard 6 units to be administered in the morning of
reduced by 25-50% if total daily dose of insulin the procedure.
requirement is very high (>1unit/kg/day). Start dextrose 5% intravenously when NBM.
Prescribe supplemental insulin as below
Interim basal insulin may not be required in elderly patients (>75
years old) with well-controlled diabetes on monotherapy.

4 hourly capillary glucose monitoring and administer short acting insulin subcutaneously if glucose
≥10mmol/l
(refer to supplemental insulin below)
 Singapore General Hospital

Supporting Documents

Title: Document No: Page 9 of 10

Guidelines on Preoperative Assessment of Diabetes 75400-SD-007
Mellitus
Issuing Department: Preoperative Evaluation Clinic Approved By:
Date Revised: 27 July 2018 A/Prof Soh Chai Rick
Version Number: 4 Head,
Issued by: Dr Hairil Rizal Abdullah, Department of Anesthesiology
Clinical Director, Perioperative Services Singapore General Hospital

Supplemental (correctional) protocol using Actrapid

If 2 or more consecutive capillary glucose readings are > 10 mmol/l, switch from LOW dose to HIGH Dose
Insulin scale.

If hypoglycaemia with capillary glucose reading <4 mmol/l: Treat hypoglycaemia. Refer to hypoglycaemia
protocol.

If persistently raised capillary glucose readings, check renal panel, venous glucose and serum ketone to look
for DKA or HHS.

Blood Glucose (mmol/l) LOW dose (default scale) HIGH dose (If pre-admission insulin
requirement is >1unit/kg/day)
10.1-14 2 4
14.1-18 4 6
18.1- 22 6 8
>22.1 8 10

When full diet is served, resume usual DM medication if there is no contraindication

References:

1. Peacock SC, Lovshin JA. Sodium-glucose cotransporter-2 inhibitors in the perioperative

setting. J Can Anesth (2018) 65:142-147
2. Duggan EW, Carlson K, Umpierrez E. Perioperative hyperglycemia management: an update.
Anesthesiology 2017 Mar; 126(3):547-560
3. Marks J.B. Perioperative Management of Diabetes. Am Fam Physician. 2003 Jan 1;67(1):93-
100
4. The NICE--‐STUDY Investigators. Intensive versus Conventional Glucose Control in Critically
Ill Patients. N Engl J Med. 009;360(13):1283--‐1297
5. Perioperative Diabetes Management. Endocrine The Medicine Consult Handbook © 2011
(http://depts.washington.edu/medcons/handbookpdfs/diabetes2011.pdf)
6. Vann M.A. Perioperative management of ambulatory surgical patients with diabetes mellitus.
Current Opinion in Anaesthesiology 2009,22:718–724
7. Frisch A, Chandra P, Smiley D, et al. Prevalence and clinical outcome of hyperglycemia in the
perioperative period in noncardiac surgery. Diabetes Care 2010;33:1783-8.
8. Lipshutz AK,.Gropper MA. Perioperative glycemic control: An evidence-based review.
Anesthesiology 2009;110:408-21.
 Singapore General Hospital

Supporting Documents

Title: Document No: Page 10 of 10

Guidelines on Preoperative Assessment of Diabetes 75400-SD-007
Mellitus
Issuing Department: Preoperative Evaluation Clinic Approved By:
Date Revised: 27 July 2018 A/Prof Soh Chai Rick
Version Number: 4 Head,
Issued by: Dr Hairil Rizal Abdullah, Department of Anesthesiology
Clinical Director, Perioperative Services Singapore General Hospital

9. Eldridge AJ, Sear JW. Peri-operative management of diabetic patients. Any changes for the
better since 1985? Anaesthesia 1996;51:45-51.
10. Meneghini L.F. Perioperative management of diabetes: Translating evidence into practice.
Cleveland Clinic J of Med 2009:76(4): 535-559

Reference Documents

1.1 Regulatory Requirements

Nil

1.2 SGH Documents

Document Number Title
75400-FM-002

1.3 Non-SGH Documents

Document Number Title
Nil