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220 Chapter 9 Endocrine and metabolic disease

Perioperative treatment of hyperglycaemia

For well-​controlled patients (HbA1c <69mmol/​mol) undergoing surgery
with a short starvation period (one missed meal) and preoperative hyper-
glycaemia (blood glucose >12mmol/​L):
• Type 1 diabetes: give SC rapid-​acting insulin analogue. Assume that
1 unit will drop blood glucose by 3mmol/​L, but take advice from the
patient wherever possible. Recheck blood glucose hourly. If surgery
cannot be delayed, commence VRIII.
• Type 2 diabetes: give 0.1 units/​kg of SC rapid-​acting insulin analogue,
and recheck blood glucose 1h later to ensure it is falling. If surgery
cannot be delayed or the response is inadequate, commence VRIII.
Hypoglycaemia
• Blood glucose <4mmol/​L is the main danger to diabetics
perioperatively. Fasting, recent alcohol consumption, liver failure and
septicaemia commonly exacerbate this.
• Characteristic signs are tachycardia, light-​headedness, sweating and
pallor. This may progress to confusion, restlessness, incomprehensible
speech, double vision, convulsions and coma. If untreated, permanent
brain damage will occur, made worse by hypotension and hypoxia.
• Anaesthetised patients may not show any of these signs. Monitor
blood sugar preoperatively and then hourly if stable, and suspect
hypoglycaemia with unexplained changes in the patient’s condition.
• If hypoglycaemia occurs, give 75mL of 20% glucose over 15min
or 150mL of 10% glucose, and repeat blood glucose after 15min.
Alternatively, give 1mg of glucagon (IM or IV); 10–​20g (2–​4 teaspoons)
of sugar by mouth or an NGT is an alternative.
Transferring from a variable-​rate intravenous insulin
infusion to subcutaneous insulin or oral treatment
Restarting oral hypoglycaemic medication
• Recommence oral hypoglycaemic agents once the patient is ready to
eat and drink.
• Be prepared to withhold or reduce sulfonylureas if the food intake is
likely to be reduced.
• Metformin should only be recommenced if the eGFR >50mL/​min/​
1.732.
Restarting subcutaneous insulin for patients already established on insulin
• Conversion to SC insulin should be delayed until the patient is able to
eat and drink without nausea and vomiting.
• Should take place when the next meal-​related SC insulin dose is due.
• Restart the normal presurgical regime. Be aware that insulin
requirement may change due to postoperative stress, infection or
altered food intake.
• Consult the diabetes team if blood sugar is outside the acceptable range
(4–​12mmol/​L).
• Ensure overlap between the VRIII and the 1st injection of the fast-​acting
insulin. The fast-​acting insulin should be injected SC with the meal, and
the VRIII discontinued 30–​60min later.
 

Diabetes mellitus 221

For patients on basal bolus insulin

• If the patient was previously on a long-​acting insulin analogue, such as
Lantus® or Levemir®, this should have been continued and so the patient
only needs to restart their normal short-​acting insulin at the next meal.
For patients on continuous subcutaneous insulin
• Commence the SC insulin infusion at their normal basal rate as long as
not at bedtime.
• VRIII should be continued until the next meal bolus has been given.
Further reading
Barker P, Creasey PE, Dhatariya K, et al.; Association of Anaesthetists of Great Britain and Ireland
(2015). Peri-​operative management of the surgical patient with diabetes. Anaesthesia, 70,
1427–​40.
Simpson AK, Levy N, Hall GM (2008). Perioperative IV fluids in diabetic patients—​don’t forget the
salt. Anaesthesia, 63, 1043–​5.