Anaes · Perioperative medicine
Perioperative management of diabetes mellitus
Also known as Perioperative diabetes · Variable rate insulin infusion · VRIII · Diabetes day of surgery
Exam-exhaustive perioperative diabetes: HbA1c discussion, day-of insulin and OHA rules, DKA versus elective pathways, VRIII principles, dexamethasone/PONV tradeoff, and hypoglycaemia recognition under anaesthesia for ANZCA Final and equivalents.
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Red flags
- Emergency abdominal sepsis may be DKA — check ketones and gases before pure 'elective diabetes' thinking.
- Hypoglycaemia under anaesthesia has no sweating complaint — check glucose on a schedule.
- SGLT2 inhibitors: euglycaemic DKA risk — hold per local guidance before elective surgery.
- Dexamethasone fixes PONV but spikes glucose — decide consciously.
- VRIII without glucose substrate causes iatrogenic hypoglycaemia.
Meet the patient
A 62-year-old with type 2 diabetes on metformin, gliclazide and empagliflozin is listed for an elective laparoscopic cholecystectomy. Her HbA1c is 72 mmol/mol and her day-of glucose is 11 mmol/L. She is second on the list and has been fasting since midnight.[1]
Three questions decide her morning and every diabetes stem: which tablet do I hold, and why?, when does she need an insulin infusion instead?, and will I still give dexamethasone? Answer those three and the day-of plan writes itself.[1][2]
References5ShowHide
- [1]Barker P, Creasey PE, Dhatariya K, et al. Peri-operative management of the surgical patient with diabetes 2015: Association of Anaesthetists of Great Britain and Ireland Anaesthesia, 2015.PMID 26417892
- [2]Dhatariya K, Levy N, Kilvert A, et al. NHS Diabetes guideline for the perioperative management of the adult patient with diabetes Diabet Med, 2012.PMID 22288687
- [3]Evans L, Rhodes A, Alhazzani W, et al. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021 Intensive Care Med, 2021.PMID 34599691
- [4]Dhatariya KK The management of diabetic ketoacidosis in adults-An updated guideline from the Joint British Diabetes Society for Inpatient Care Diabet Med, 2022.PMID 35224769
- [5]De Oliveira GS Jr, Castro-Alves LJ, Ahmad S, Kendall MC, McCarthy RJ Dexamethasone to prevent postoperative nausea and vomiting: an updated meta-analysis of randomized controlled trials Anesth Analg, 2013.PMID 23223115