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2.  What Is Pre-operative Diabetes Management..? – Introduction
Pre-operative diabetes management refers to the
medical care and strategies implemented to optimize
blood glucose levels and overall health in individuals
with diabetes before undergoing a surgical procedure.
Impact of Hyperglycemia: Results in delayed
wound healing, higher infection rates, prolonged
hospital stays, and increased postoperative mortality
Benefits of Glucose Control: Achieving good
glucose control during the perioperative period is
crucial for positive post-surgical outcomes
Severity Depends On/ Anaesthesia Type /Surgery
Type/Influence on Hyperglycaemia
Dogra P, Jialal I. Diabetic Perioperative Management. [Updated 2022 Jun 19]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK540965/

3.  Prevalence of
Hyperglycemia:
 Common occurrence in
surgeries.
 General surgery: 20-40%
affected.
 Cardiac surgery: 80-90%
affected.
 Defined as blood glucose
above 140 mg/dl.
Sudhakaran S, Surani SR. Guidelines for Perioperative Management of the Diabetic Patient. Surg Res Pract. 2015;2015:284063. doi: 10.1155/2015/284063. Epub 2015 May 19. PMID: 26078998; PMCID: PMC4452499.

4. PERIOPERATIVE DIABETES MANAGEMENT
The perioperative period divides into three phases-
 Preoperative  Intraoperative  Postoperative
Sudhakaran S, Surani SR. Guidelines for Perioperative Management of the Diabetic Patient. Surg Res Pract. 2015;2015:284063. doi: 10.1155/2015/284063. Epub 2015 May 19. PMID: 26078998; PMCID: PMC4452499.

5. 1. Preoperative Phase:
Preoperative Phase Details
A) History - Diabetes Type: 1 or 2
- Management: Medications, lifestyle
- Glycemic Control: Recent levels, target range
- Complications: Microvascular, macrovascular
- Susceptibility to Hypoglycemia: Medications,
symptoms
- Antidiabetic Drugs: Types, adherence
- Surgical Details: Ambulatory/Inpatient,
Elective/Emergent, Expected Duration, Fasting
B) Glycated Hemoglobin A1c - Check preoperative HbA1c
- Consider postponing elective surgery if HbA1c >
10%
C) Oral Antihyperglycemic & Non-Insulin
Injectable
- Safety concerns with metformin, sulfonylureas,
SGLT-2 inhibitors in perioperative settings
- Hold medications on the day of surgery (except
SGLT-2 inhibitors)
- Emerging interest in DPP-4 inhibitors and GLP-1
agonists; guidelines evolving
D) Insulin Therapy - Adjust home insulin dose before surgery
- Consider reduced doses for high-risk patients
- Adjust ultra-long-acting insulin three days before
surgery with guidance
E) Preoperative Blood Glucose Check - Check blood glucose in the preoperative area
Consider postponing surgery for severe
hyperglycemia or metabolic decompensation
Sudhakaran S, Surani SR. Guidelines for Perioperative Management of the Diabetic Patient. Surg Res Pract. 2015;2015:284063. doi: 10.1155/2015/284063. Epub 2015 May 19. PMID: 26078998; PMCID: PMC4452499.

6. Intraoperative Glycemic
Management Details
Target Range:
- No consensus; suggested 150-
200 mg/dL during surgery
- 140-170 mg/dL linked to lowest
adverse outcome risk
Monitoring:
- Utilize inpatient blood glucose
measurement systems
Procedure Length:
- Short procedures: preoperative glucose
maintenance
- Complex procedures: consider variable
rate IV insulin infusion
IV Insulin Infusion:
- Regular IV insulin active for 1 hour,
half-life 7 minutes
- Initiate at 0.5–1 U/hour in type 1, 2-
3 U/hour or higher in type 2
- Static and adjustable algorithms for
infusion rate adjustment
Continuous GIK Infusion:
- Inotropic, metabolic therapy in critical
disease states
- Mechanism: Lower circulating free
fatty acids, increase myocardial energy
production, stabilize potassium
- Not suitable for individual glucose or
insulin level control
2. Intraoperative phase
Sudhakaran S, Surani SR. Guidelines for Perioperative Management of the Diabetic Patient. Surg Res Pract. 2015;2015:284063. doi: 10.1155/2015/284063. Epub 2015 May 19. PMID: 26078998; PMCID: PMC4452499.

7. Postoperative Phase Details
A) Ambulatory
- Resume previous
antihyperglycemic regimen for
stable ambulatory patients after
recovery
B) Non-Critically Ill
- Admit to surgical/medical ward
with subcutaneous insulin
- Adjust insulin based on oral
intake (basal, nutritional,
correctional components)
C) Critically Ill
- Manage in intensive care with
continuous insulin infusion
- Transition to subcutaneous
insulin when stable; overlap
intravenous and subcutaneous
Insulin Dosing Transition
- Use infusion rate, weight, or
home insulin dose for basal
insulin calculation
- Monitor glycemia with
correctional insulin; avoid sole
use of correctional insulin
- Adjust regimen based on glucose
trends and clinical status
3.Postoperative Phase
Sudhakaran S, Surani SR. Guidelines for Perioperative Management of the Diabetic Patient. Surg Res Pract. 2015;2015:284063. doi: 10.1155/2015/284063. Epub 2015 May 19. PMID: 26078998; PMCID: PMC4452499.

8. Preoperative
management key points
Intraoperative
management key points
Postoperative
management key points
(i) Verify target blood
glucose concentration with
frequent glucose monitoring
(ii) Use insulin therapy to
maintain glycemic goals
(iii) Discontinue biguanides,
alpha glucosidase inhibitors,
thiazolidinediones,
sulfonylureas, and GLP-1
agonists
(iv) Consider cancelling
nonemergency procedures if
patient presents with
metabolic abnormalities
(DKA, HHS, etc.) or glucose
reading above 400–
500 mg/dL
(i) Aim to maintain
intraoperative glucose levels
between 140 and 170 mg/dL
(ii) Physicians must take
length of surgery into
account when determining
an intraoperative glucose
management strategy
(iii) For minor surgery,
preoperative glucose
protocols may be continued
(iv) IV insulin infusion is
being promoted as a more
efficient method of glycemic
control for longer or more
complex surgeries
(i) Target postoperative
glycemic range between 140
and 180 mg/dL
(ii) In the event a patient is
hypoglycemic after surgery,
begin a dextrose infusion at
approximately 5–10 g/hour
(iii) Ensure basal insulin
levels are met, especially in
type 1 diabetic patients
(iv) Postprandial insulin
requirements should be
tailored according to the
mode in which the patient is
receiving nutrition
(v) Supplemental insulin can
be used to combat
hyperglycemia and restore
blood glucose values back to
target range
Sudhakaran S, Surani SR. Guidelines for Perioperative Management of the Diabetic Patient. Surg Res Pract. 2015;2015:284063. doi: 10.1155/2015/284063. Epub 2015 May 19. PMID: 26078998; PMCID: PMC4452499.

9.  Importance of Diabetes Management in Surgery:
 Metabolic
Perturbations Surgery
disrupts glucose
balance, leading to
hyperglycaemia.
 Risk Factors Hyperglycaemia
risks |include sepsis,
endothelial
dysfunction,cerebral ischemia,
and impaired wound healing
 Stress Response
|Surgery-induced
stress can trigger
diabetic complications
like DKA or HHS
 Positive Outcomes
 Careful glucose
management during major
surgeries improves overall
outcomes.
 Economic Impact
Diabetics have more
hospitalizations,
longer stays, and
higher costs
 Complications Diabetics
face more surgical wound
complications without
well-managed glycemic
levels.
Sudhakaran S, Surani SR. Guidelines for Perioperative Management of the Diabetic Patient. Surg Res Pract. 2015;2015:284063. doi: 10.1155/2015/284063. Epub 2015 May 19. PMID: 26078998; PMCID: PMC4452499.

10. Key points -
 Perioperative Glycemic Control:
 Various protocols exist, requiring clinical judgment for specific adjustments.
 Insight provided into glucose management goals pre-, intra-, and
postoperatively.
 Variable Nature of Glucose Homeostasis:
 Perioperative period exhibits significant variability in glucose, electrolytes, and
acid-base status.
 Continuous monitoring of blood glucose levels is essential.
 Consideration of Normal Diabetic Regimen:
 Physicians should be mindful of a patient's usual diabetic protocol.
 Transition patients back to their normal glycemic management
postoperatively.
 Impact of Careful Perioperative Glucose Management:
 Reduces surgical complications and hyper- or hypoglycemic sequelae.
 Ultimately improves patient morbidity and mortality.
 Conclusion:
 Emphasizes the importance of careful perioperative glucose management for
overall patient well-being.
Sudhakaran S, Surani SR. Guidelines for Perioperative Management of the Diabetic Patient. Surg Res Pract. 2015;2015:284063. doi: 10.1155/2015/284063. Epub 2015 May 19. PMID: 26078998; PMCID: PMC4452499.

11. Thank you