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Guidelines for the Management of Diabetes Mellitus in the peri-operative period |
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Pre and peri operative periods
Insulin Dependent Diabetes Continue normal insulin until the day of the operation. However if the diabetic control is poor, contact the diabetes team for advice. All patients with diabetes should be first on the list. The following applies with IDDM whether admitted for major or minor surgery.
Morning list Fast patients from midnight. Withhold insulin on morning of surgery but set up insulin/ dextrose IVI at 07:00.
Afternoon list Give breakfast by 07:00 and give usual insulin beforehand, providing it is only short acting. If the patient is usually on a mixture of long and short acting insulin give 30% of the total normal dose as a short acting insulin e.g. Actrapid and withhold any long acting insulin. St up insulin / dextrose by 11:00.
Non-insulin Dependent Diabetes: OHAs Minor procedures Fast patient as above and omit oral medication. Check capillary glucose on admission. No need for IV insulin assuming glucose < 11 mmol/l. Give morning dose of OHA as soon as ready to eat and drink post-operatively. Time discharge home as any other patient.
Major procedures Continue usual tablets until the day of the operation. If control is poor, i.e. glucose levels > 10mmol/l contact the diabetic team before the day of surgery.
Morning list Starve from midnight and omit OHA. Set up insulin / dextrose IVI at 07:00
Afternoon list Give light early breakfast and usual OHA by 07:00, set up insulin/ dextrose IVI by 11:00
Non-insulin Dependent Diabetes: Diet Controlled If well controlled, admit on day of surgery. Check capillary glucose on admission. If > 10mmol/l there is no need to cancel surgery, but get diabetic team review before discharge to consider long term control. For minor procedures treat otherwise as non diabetic. For major procedures if blood glucose > 11mmol/l put up insulin/ dextrose IVI to cover surgery and arrange diabetes team to review post operatively.
Post Operative Care
Good metabolic control reduces post operative catabolism and the risk of infection and promotes wound healing. Blood glucose levels should be kept between 4—7mmol/l. The stress of surgery +/ - infection may lead to increased blood glucose levels and insulin needs. For straightforward operations where the expected length of stay is 5—7 days and where the patient is expected to resume normal diet within 24—36 hours, the following guidelines may be used without the need for diabetic review.
Insulin Dependent Diabetes Major and minor procedures: keep sliding scale up until the patients are able to tolerate normal diet. As soon as they can, stop the IVI regime and restart normal insulin. Check pre– and post-prandial capillary glucose levels until the day of discharge home. If blood glucose levels consistently > 7mmol/l pre prandial contact the diabetes team.
Non insulin Dependent Diabetes Minor procedures Insulin infusion will not be needed. Give normal OHA/ insulin dose as soon as normal diet is tolerated. Time discharge as for non diabetic.
Major procedures Keep sliding scale till normal diet resumed, then give usual OHA / insulin. Check pre– and post-prandial capillary blood glucose levels until ready for home. If capillary blood glucose levels consistently > 10mmol/l contact the diabetic team.
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For many patients the stress of hospital admission may lead to a deterioration in their diabetic control. The aim should be to maintain blood glucose levels between 4—7 mmol/l. |