Diabetes in surgery (evidence based management protocol)

Diabetes and Surgery

DR. HRIDAY RANJAN ROY

Assistant Professor (Surgery)

Department of Surgery

Rangpur Medical College & Hospital

Importance of controlling Diabetes in Surgery

It is critical to control diabetes during surgery (pre-, per- and postoperatively). The causes are: 1. Tight control is needed to avoid hyper- or hypoglycemia,2. Patient need fasting (NPO) for operative procedures,3. So adjustment of glucose level control become critical

Standard Protocol

I am going to present some evidence based practice in which glucose level control protocol is gold standard.

Preoperative glucose level

Should be maintained at: Fasting <90mg/dlPostprandial <180mg/dlHb1c <7%

Journal of Indian Medical association

2010 Jan; 108(1): 52-5

Peroperative and ICU

Glucose level must be maintained in between 140-180mg/dl.(80-110mg/dl protocol has chance to develop

fatal hypoglycemia and 12.1% mortality)

Journal of Indian Medical association

2010 Jan; 108(1): 52-5

Sliding Scale

Use of Sliding scale insulin therapy during operation is no more useful and should be stopped.

JAMA 2009 Jan 14; 301(2)213-4

Why to control DM during Surgery25% diabetic patient need surgery.Hyperglycemia during surgery may produce:

1. Dehydration (Osmotic Diuresis)2. Electrolyte imbalance3. Impair wound healing4. Increase infection rate5. Chance to develop keto acidosis6. Has detrimental effect on CVS and renal function.

Archives of Internal Medicine 1999 Nov 8; 159: 2405-2411

Surgical trauma raise glucose level

• Operative trauma has chance to develop hyperglycemia due to raised catecholamines and glucagon, increase glucose production by liver and decrease utilization by peripheral tissues.

• In the other hand, fasting (for operative purpose) along with insulin may produce hypoglycemia which is more detrimental.


Protocol of Control

Protocol for control of glucose level: DM with diet= nothing neededDM with Oral (metformin)= discontinue on the day of surgeryDM with insulin= convert to intermediate acting


Protocol of Control (Cont..)

If morning fasting is needed for surgery, 1/3, 1/2, or 2/3 of usual insulin dose. If fasting need to be continued (for surgery), 5gm glucose/hour (1000 ml DA or DNS in 10 hours) with usual insulin dose.

Archives of Internal Medicine

1999 Nov 8; 159: 2405-2411


I/V insulin protocol (regular soluble insulin): Half life of IV insulin < 10 minutes. So continuous or more frequent dose should be administered.



2 protocols:

1. Intermittent bolus technique= 10 U/2 hrs. Or if blood glucose>11mmol/L= 5 U/ hour.

2. I/V continuous: 0.5 to 5 U with glucose. Exactly 0.3 U / gm of glucose. This means 0.3X50= 15 U / 50gm (1000ml of DA or DNS).

Archives of Internal Medicine

1999 Nov 8; 159: 2405-2411

GKI protocol

GKI protocol (Glucose-Pottasium-Insulin): Very important regim:

500ml 10% glucose (50gm) + 10 mmol pottasium + 15 U insulin. @100ml/hour= 1600 drops/ 60 min= 26 d/min). Insulin increment may be needed if blood glucose > 180mg%.


Crit Care Med 2007; 35 (9 suppl): S503-S507

Peroperative control to 80-110gm% should not be practiced as has chance to develop detrimental hypoglycemia. Rather 140-180gm% maintenance is safe. Hypo= <2.2 mmol/L or <40mg%= 12.1% mortality.

Thank you All

Health & Medicine

Diabetes in surgery (evidence based management protocol)