Perioperative Management of Diabetes Mellitus Author: Nadia A. Khan, MD; William A. Ghali, MD; Susan E. Spratt, MD; Melanie E. Mabrey, MSN, ACNP, BC-ADM
Editorial changes - 2012-01-03
Author information and module status
Elements of Risk
Whom and How to Assess
Interventions to Decrease Risk
Patient Education
Follow-up
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References
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Follow-up
  • Employ consistent follow-up measures to improve glycemic management.
  • Evaluate patients for postoperative cardiac and infectious complications.
Elements of Follow-up for Patients with Diabetes (table)

Employ consistent follow-up measures to improve glycemic management. C

  • Monitor glucose levels frequently:
    • In patients who are eating, monitor glucose levels up to five times per day (pre-meal for breakfast, lunch, and dinner as well as bedtime)
    • In patients who are not eating but are receiving continuous (24 h/d) parenteral or enteral nutrition, monitor glucose every 4 to 6 hours
    • Check glucose at 3 AM if a change in basal insulin has been made or the patient has had hypoglycemia in the past 24 hours
    • Consider testing patients with type 1 diabetes even more frequently
  • Adjust basal and prandial insulin at least daily, and review the total amount of correction dose insulin used in the past 12 to 24 hours and add it to the scheduled insulin dose.
  • Administer insulin according to scheduled basal and prandial/nutritional needs, and give correction dose insulin if the blood glucose level is higher than the goal.
  • Do not withhold basal insulin.
  • Recognize that the frequent use of “sliding-scale insulin,” which is the use of correction dose insulin alone, without scheduled basal insulin, is no longer the standard of care.
  • Measure other electrolytes, such as potassium, as needed:
    • For patients on insulin infusions, measure potassium levels every 6 hours
    • Note that potassium levels may need to be checked more or less frequently depending on renal function and concomitant drug use, such as with ACE inhibitors, angiotensin-receptor blocking agents, potassium-sparing diuretics, or other diuretics
  • Measure bicarbonate levels, ketones, and anion gap every other day or as needed for patients who are insulin-deficient to monitor for DKA.
  • Aim to keep glucose levels within the target ranges and avoid hypoglycemia and marked hyperglycemia.
  • Recognize the factors that increase the risk of inpatient hypoglycemia:
    • Change in caloric intake
    • Taper in glucocorticoid dose
    • Failure to adjust insulin dose daily based on glucose trends
    • Use of “sliding-scale insulin” alone for longer than 24 hours
    • Administration of meals and insulin dose at separate times
    • Use of sulfonylurea therapy in patients with renal or liver failure
    • Not adjusting therapy if there is renal or liver failure
  • If postoperative hyperglycemia is difficult to control, consider diet, dextrose-containing solutions, infection, or DKA as the cause of hyperglycemia.
  • Follow dietary intake at least daily to guide reintroduction of outpatient medications.
  • Reintroduce outpatient drug therapy as outlined in Postoperative Drug Intervention.
  • See table Elements of Follow-up for Patients with Diabetes.
  • See table Acceptable Insulin Regimens for Different Inpatient Scenarios.
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Evaluate patients for postoperative cardiac and infectious complications. C

  • Use elements of the history, physical examination, and further testing as needed to assess for postoperative MI or wound infection or other infections.
  • Recognize that hyperglycemia may be a sign of infection.
  • See table Elements of Follow-up for Patients with Diabetes.
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FAQs
Melanie E. Mabrey, MSN, ACNP, BC-ADM has no financial relationships with pharmaceutical companies, biomedical device manufacturers, or health-care related organizations. Nadia A. Khan, MD has no financial relationships with pharmaceutical companies, biomedical device manufacturers, or health-care related organizations. Susan E. Spratt, MD has no financial relationships with pharmaceutical companies, biomedical device manufacturers, or health-care related organizations. William A. Ghali, MD has no financial relationships with pharmaceutical companies, biomedical device manufacturers, or health-care related organizations.
Deborah Korenstein, MD, FACP, Co-Editor, PIER, has no financial relationships with pharmaceutical companies, biomedical device manufacturers, or health-care related organizations. Richard B. Lynn, MD, FACP, Co-Editor, PIER, has no financial relationships with pharmaceutical companies, biomedical device manufacturers, or health-care related organizations.

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