9.3.0.0 Perioperative Care
Many standards for perioperative care lack a robust evidence base. However, the following approach (69) may be considered:
1.Target glucose range for the perioperative period should be 80–180 mg/dL (4.4–10.0 mmol/L).
2.Perform a preoperative risk assessment for patients at high risk for ischemic heart disease and those with autonomic neuropathy or renal failure.
3.Withhold metformin the day of surgery.
4.Withhold any other oral hypoglycemic agents the morning of surgery or procedure and give half of NPH dose or 60–80% doses of long-acting analog or pump basal insulin.
5.Monitor blood glucose at least every 4–6 h while NPO and dose with short- or rapid-acting insulin as needed.
A review found that perioperative glycemic control tighter than 80– 180 mg/dL (4.4–10.0 mmol/L) did not improve outcomes and was associated with more hypoglycemia (70); therefore, in general, tighter glycemic targets are not advised. A recent study reported that, compared with the usual insulin dose, on average an approximate 25% reduction in the insulin dose given the evening before surgery was more likely to achieve perioperative blood glucose levels in the target range with decreased risk for hypoglycemia (71).
In noncardiac general surgery patients, basal insulin plus premeal short- or rapid-acting insulin (basal-bolus) coverage has been associated with improved glycemic control and lower rates of perioperative complications compared with the traditional sliding scale regimen (short- or rapid-acting insulin coverage only with no basal insulin dosing) (38,72).