One discussion this week included management of perioperative hyperglycemia.

Reference: Duggan EW, Carlson K, Umpierrez GE. Perioperative hyperglycemia management: an update. Anesthesiology. 2017 Mar;126(3):547-560. doi: 10.1097/ALN.0000000000001515.

Summary:  A substantial body of literature demonstrates a clear association between perioperative hyperglycemia and adverse clinical outcomes. The risk for post-operative complications and increased mortality relates to both long-term glycemic control and to the severity of hyperglycemia on admission and during the hospital stay. This study reports on the prevalence, diagnosis and pathophysiology of perioperative hyperglycemia and provides a practical outline for the management of surgical patients with diabetes and hyperglycemia.

The sections addressed include:

• Metabolic consequences of surgical stress and anesthesia
• Prevalence of hyperglycemia and diabetes in surgical patients
• Preoperative period
• Diabetes, fasting and feeding
• Intraoperative period
• Postoperative period
• Glycemic targets
• Pre-operative glycemic management
• Intraoperative glycemic management
• Post-operative glycemic management for non-ICU patients
• Transitioning from IV to SC insulin
• Insulin pump therapy
• Hypoglycemia
• Glucose monitoring in the perioperative period

CONCLUSION: Hyperglycemia is common in surgical patients. Current data demonstrates an association between elevated BG and a risk of perioperative complications in diabetic and non-diabetic patients. Insulin administration intra- and post-operatively has been shown to improve clinical outcomes. Individual patient characteristics and surgical case factors are considered when choosing subcutaneous insulin or an insulin infusion. Both are appropriate options on the day of surgery. Blood glucose values of 180 mg/dL (10 mmol/L) or higher are treated with insulin. Target range for the perioperative period is 140-180 mg/dL (7.7-10 mmol/L). Post-operatively, surgical floor patients with poor or uncertain oral intake are treated with once daily basal insulin. Prandial insulin is added when patients tolerate oral intake. Increasing evidence suggests a role for incretin therapy during the peri-operative period in patients with type 2 diabetes.

Multiple teams care for a surgical patient during the hospital course (anesthesiology, surgery, critical care medicine, internal/hospital medicine and endocrinology). Therefore, multidisciplinary groups within an institution should work together to create appropriate protocols for hyperglycemia screening, monitoring and treatment to minimize errors and to better care for patients.