Diabetic Perioperative Management


Article Author:
Prerna Dogra


Article Editor:
Ishwarlal Jialal


Editors In Chief:
Wanda Wright
Cynthia Oster


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Trevor Nezwek
Radia Jamil
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Beenish Sohail
Nazia Sadiq
Hajira Basit
Phillip Hynes


Updated:
8/10/2019 8:52:10 AM

Introduction

In both diabetic and non-diabetic population, hyperglycemia in the perioperative period is an independent marker of poor surgical outcomes (delayed wound healing, increased rate of infection, prolonged hospital stay, higher postoperative mortality).[1][2][3][4] Hyperglycemia (greater than 140 mg/dl) is a frequent occurrence with a prevalence of 20 to 40% in the general surgery and 80 to 90% in the cardiac surgery population.[2][4][5][6]

The stress of surgery, anesthesia, and illness increases secretion of counter-regulatory hormones (cortisol, glucagon, growth hormone, catecholamines), which in turn causes decreased insulin secretion, increased insulin resistance, decreased peripheral utilization of glucose, increased lipolysis and proteolysis. As a consequence, gluconeogenesis and glycogenolysis increase, which subsequently results in worsening hyperglycemia termed as stress hyperglycemia. Uncontrolled hyperglycemia instigates osmotic diuresis (causing fluid and electrolyte imbalance), ketogenesis and increased generation of pro-inflammatory cytokines with resultant mitochondrial injury, endothelial dysfunction and immune deregulation.[7][8] Hence, achieving good glucose control during the perioperative period is associated with beneficial post-surgical outcomes.[4][5]

The severity of hyperglycemia also depends on the type of anesthesia and surgery, with increased glucose elevations seen in cases of general anesthesia or thoracic/abdominal surgeries as opposed to epidural/local anesthesia or peripheral/laparoscopic surgeries, respectively.[9][10][11]

Issues of Concern

PERIOPERATIVE MANAGEMENT

The perioperative period divides into three phases-

  • Preoperative
  • Intraoperative
  • Postoperative

1. Preoperative

A) History

It is essential to obtain a detailed account regarding

  • Diabetes mellitus (DM) – the type of diabetes, management (lifestyle modifications and medications), current glycemic control, related complications (nephropathy, neuropathy, retinopathy, cardiovascular disease) and susceptibility to hypoglycemia including hypoglycemic unawareness. If on antidiabetic drugs, it is imperative to know the details of the regimen and about medication adherence.
  • Surgery - ambulatory/inpatient, elective/time-sensitive/emergent, the anticipated duration of surgery and fasting.

B) Glycated Hemoglobin A1c

A preoperative hemoglobin A1c (HbA1c) should be checked, if not tested in the preceding three months. Multiple studies have looked at the association of HbA1c and surgical outcomes and based on existing literature; it is controversial whether elevated HbA1c is linked to poor postoperative outcomes or is just a marker of poor perioperative glucose control.[12][13][14][15][16] Besides, there is no evidence proving better outcomes by deferring the surgery for better glycemic control. Although there are no validated HbA1c cut-off values, it may be plausible to postpone an elective surgery if HbA1c is higher than 10%. Procedures that are of emergent or time-sensitive nature should not be delayed to achieve a target HbA1c; instead, the focus should be on optimizing perioperative glucose control. Nevertheless, it is recommended to obtain a preoperative HbA1c to assess glycemic control and recognize patients with undiagnosed diabetes.

C) Oral Antihyperglycemic & Non-Insulin Injectable

There is concern regarding the safety and efficacy of oral antihyperglycemic and non-insulin injectable in the perioperative or hospital settings. Metformin can lead to the development of lactic acidosis in cases of renal dysfunction or with use of intravenous contrast, sulfonylureas and other insulin secretagogues risk hypoglycemia, sodium glucose cotransporter-2 (SGLT-2) inhibitors carry the risk of euglycemic ketoacidosis in fasting, or acutely ill patients, glucagon-like-peptide-1 receptor (GLP-1) agonists can worsen nausea and vomiting by delaying gastric emptying. Furthermore, the delayed onset and prolonged duration of action make it challenging to titrate these medications to achieve optimal glycemic control over a short period. Currently, the recommendations are for holding these medications on the day of surgery except for SGLT-2 inhibitors,[17][18] which should be held minimal 24-hours before surgery. In cases of emergent surgery or illness, these medications should be stopped immediately.

Recent evidence from randomized controlled trials such as SITA-HOSPITAL trial demonstrated that dipeptidyl peptidase-4 (DPP-4) inhibitors are both safe and efficacious in medical and surgical patients with mild to moderate hyperglycemia; however some such as saxagliptin predispose to heart failure.[19][20][21] However, recent guidelines published by ADA, do not recommend the use of DPP-4 inhibitors in the inpatient setting. There is also an emerging interest regarding the use of GLP-1 agonists in the hospital setting, and multiple large RCTs are currently underway.[22]

D) Insulin Therapy

Patients who are on home insulin therapy should reduce the dose of long-acting basal insulin (glargine, detemir) by 20-25% the evening before surgery.[23] If they routinely take basal insulin only in the morning, then the reduced dose should instead be administered on the morning of surgery. Patients who are on twice daily glargine or detemir should reduce the dose by 20 to 25%, in the evening prior as well as the morning of surgery.  However, in patients who take high doses of basal insulin (>60% of total daily insulin) or total daily insulin dose is greater than 80 units or are at high risk of hypoglycemia (elderly, renal or hepatic insufficiency, prior hypoglycemic episodes); basal insulin dose should be reduced by 50 to 75% to minimize hypoglycemia risk. For the ultra-long-acting insulin, owing to their long half-life, dose reductions should be made three days before surgery with the help of an endocrinologist or diabetes care team. In cases of intermediate-acting insulin such as neutral protamine hagedorn (NPH), the usual dose is administered the evening prior and reduced by 50% on the morning of surgery. Patients who are on premixed insulin (NPH/Regular 70/30, aspart protamine/aspart 75/25, etc.), should preferably receive long-acting insulin the evening prior instead of their premixed formulation. However, this may not be feasible in a lot of these patients. In such scenarios, the premixed insulin is reduced by 50% on the morning of surgery followed by initiation of dextrose-containing intravenous solutions. Alternatively, these patients can be asked to skip the morning dose and arrive early to the preoperative area where they can receive a long-acting formulation.[Image]

During the fasting state, nutritional (or prandial) insulin is held and subcutaneous correctional insulin initiated with blood glucose (BG) monitoring every 4 to 6 hours.  Most institutions have standardized correctional insulin scales based on different insulin sensitivities.[24] [Image]

In critically ill patients, continuous intravenous infusion (CII) using regular insulin is the preferred regimen. In the setting of hemodynamic instability/hypothermia/peripheral vasoconstriction, subcutaneous insulin is absorbed poorly, and intravenous insulin is preferable due to more predictable pharmacokinetics. Furthermore, intravenous insulin allows for easy dose titration due to a shorter duration of action (10 to 15 minutes) and omits the need for multiple injections. Use of CII should always be governed by a validated institutional protocol that includes a standardized approach for infusion preparation, initiation, titration and monitoring.[25]

Diabetic patients should preferably be scheduled for surgery early in the day. It is recommended to check the blood glucose in the preoperative area. Hypoglycemia (BG less than 70 mg/dl) treatment is with glucose tablets/gels or intravenous dextrose solutions. In cases of severe hyperglycemia (BG greater than 250 mg/dl) or metabolic decompensation (diabetic ketoacidosis or hyperglycemic hyperosmolar syndrome), it is prudent to postpone surgery by a couple of hours for better glycemic control.

2. Intraoperative

Hyperglycemia (over 180 mg/dl), in surgeries of shorter duration (<less than 4 hours) with expected hemodynamic stability and minimal fluid shift,  can be managed with 2-hourly subcutaneous correctional insulin (preferably rapid-acting insulin) and BG checks. In surgeries that may involve hemodynamic fluctuations, massive fluid shifts or last longer than 4 hours duration; BG greater than 180 mg/dl should be managed with intravenous insulin infusion, and BG monitored every 1 to 2 hours.

3. Postoperative

In the post-anesthesia care unit (PACU), it is imperative to review the intraoperative hyperglycemia management and continue close glucose monitoring with either intravenous or subcutaneous insulin.

A) Ambulatory

After recovery in the PACU, ambulatory surgery patients who are stable and tolerating oral intake can be discharged home on the previous antihyperglycemic regimen.

B) Non-critically Ill

Non-critically ill patients who require hospitalization are admitted from PACU to the surgical/medical ward on subcutaneous (SC) insulin. In the case of poor or no oral intake, basal plus correctional insulin is preferred [26]. While in a patient with regular oral intake, the insulin regimen should consist of basal, nutritional and correctional components.

  • Basal insulin: Controls hyperglycemia when a patient is not eating (at night, in between meals or when fasting) and can be given as long-acting insulin (glargine or detemir) once or twice daily.
  • Nutritional insulin: Also referred to as meal-time or prandial insulin; helps control hyperglycemia related to carbohydrate intake (meals, enteral or parenteral nutrition), with either rapid-acting insulin (lispro, aspart or glulisine) or short-acting insulin (regular).
  • Correctional insulin: Is used to counteract hyperglycemia that is above the goal; with either rapid-acting or short-acting insulin. When correctional insulin is given in addition to nutritional insulin, then the same formulation is combined into one single dose.

Insulin regimen can be dosed based on weight or pre-hospitalization regimen. Patients on home insulin regimen with good glycemic control should have their basal insulin reduced by 20 to 25% if the oral intake is inadequate. For weight-based dosing; in an average patient, the starting total daily dose (TDD) of insulin is 0.4 to 0.5 U/Kg/day; in insulin-sensitive patients (type 1 DM, insulin naïve, elderly, malnourished, renal/hepatic insufficiency, frequent hypoglycemia) starting dose should be reduced to 0.2 to 0.3 U/Kg/day and in insulin resistant (obese, on high-dose steroids) starting dose should be increased to 0.6 to 0.7 U/Kg/day. If a patient has features belonging to both insulin sensitive and resistant categories, then it is safer to dose as insulin-sensitive. Once the TDD is determined, half of TDD is administered as basal insulin, and 1/6 of TDD will be administered as nutritional insulin with each of the three meals.[27][28] When eating, BG is generally monitored four times a day (before meals and at bedtime), and correctional insulin administered accordingly. The patient who is receiving nothing by mouth should have BG monitored every 6 hours for correction with regular insulin or every 4 hours for correction with rapid-acting insulin.

C) Critically Ill

Critically ill patients should be managed in medical or surgical intensive care unit with continuous insulin infusion (CII) with regular insulin, with BG monitoring every 1 to 2 hours, as dictated by institutional protocol. The transition from CII to long or intermediate-acting SC insulin is done once these patients are hemodynamically stable with no vasopressor requirement, have optimal glycemic control with minimal variability, and a steady infusion rate in the past 6 to 8 hours. Due to the extremely short half-life of intravenous insulin and delayed onset of action of long/intermediate-acting insulin, it is essential to overlap IV and SC insulin by 2 to 3 hours. Premature discontinuation of IV insulin creates a hiatus in the basal insulin supply which risks rebound hyperglycemia or metabolic decompensation (especially in type 1 diabetes).

Subcutaneous basal insulin at the time of transition is dosed based on either (a) the rate of insulin infusion;, or (b) weight, or (c) home insulin dose. When using the rate of infusion to calculate the basal insulin dose, the average rate of infusion over the last 6 to 8 hours gets extrapolated to 24 hours. Seventy to eighty percent of this extrapolated dose represents TDD. In a patient with minimal or no caloric intake, 100% of the calculated TDD is administered as basal while in patients with optimal caloric intake 50% is given as basal and 50% as nutritional insulin. For the weight-based method, TDD is calculated similarly to non-critically ill patients, half of which is a basal dose and the other half as nutritional insulin.  In patients with good glycemic control on home insulin therapy, 70 to 80% of the home basal insulin dose can be administered at the time of transition. After the transition, similar to non-critically ill patients, hyperglycemia is managed with correctional insulin every 4 to 6 hours in a fasting patient and four times a day (before to meals and at bedtime) in a patient who is eating.[29][30]

Due to unpredictable glycemic fluctuations, the sole use of correctional insulin is not recommended.[31][32] Additionally, premixed insulin regimens should be avoided in the perioperative setting due to the increased risk of hypoglycemia.[33] Use of oral or non-insulin antihyperglycemic is an area of active research and currently not recommended for glucose management in these patients.[34]

The insulin dosing explained in this article is just a starting point and nearly all patients will require ongoing adjustments to their insulin regimen based on blood glucose, nutritional intake, and changes in clinical status. Moreover, glucose trends are more important than individual BG readings when making adjustments to the regimen.

Clinical Significance

In critically ill patients, multiple randomized controlled trials (RCTs) like NICE-SUGAR  study have compared conventional (less than 180 mg/dl) versus intensive (81 to 108 mg/dl) glucose control with results remarkable for a higher incidence of severe hypoglycemia and increased mortality in patients subjected to intensive glucose control.[5][35][36][37] However, due to the lack of RCTs in the non-critically ill patients, most of the data is extrapolated from studies conducted on the critically ill. 

Multiple societies have put forth guidelines for optimal glucose management in the perioperative period. For patients undergoing ambulatory surgery, Society for Ambulatory Anesthesia recommends intraoperative blood glucose (BG) levels less than 180 mg/dl. In critically ill patients, the Society of Critical Care Medicine recommends initiating insulin therapy for BG higher than 150 mg/dl, the American College of Physicians advises against the use of intensive insulin therapy with a BG target of 140 to 200 mg/dl. The Society of Thoracic Surgeons advocates intra-operative blood glucose less than 180 mg/dl and lower than 110 mg/dl in the pre-meal or fasting state. In the non-critically ill hospitalized patients, Endocrine Society recommends pre-meal glucose targets less than 140 mg/dl and random glucose levels lower than 180 mg/dl while the Joint British Diabetes Societies propose blood glucose levels of 108 to 180 mg/dl in most patients with an acceptable range between 72 to 216 mg/dl. The Endocrine Society also outlines higher target glucose of under 200 mg/dl is acceptable in non-critically ill hospitalized patients with terminal illness and with limited life expectancy or at high risk for hypoglycemia. American Diabetes Association (ADA) recommends a target glucose range of 80 to 180 mg/dl in the perioperative period and 140 to 180 mg/dl for the majority of critically ill and non-critically ill patients.[34].

Although the optimal glycemic target remains unclear, a reasonable goal in the majority of perioperative patients is to maintain blood glucose in the range of 140 to 180 mg/dl with the intent of avoiding both hypoglycemia (under 70 mg/dl) and severe hyperglycemia (over 180 mg/dl).

Other Issues

Type 1 Diabetes Mellitus

Due to minimal to no pancreatic beta-cell function, type 1 diabetics should have a basal-supply of insulin at all times (even if nothing by mouth), either subcutaneously or intravenously. Failure to do so can cause them to decompensate into diabetic ketoacidosis easily. 

Subcutaneous Insulin Pumps

In recent years, the use of an insulin pump has increased exponentially, especially in type 1 diabetes. Use of insulin pump in the hospital setting during the pre-/postoperative period must be guided by clear institutional policies and patient’s ability to manage the pump.[38][39] Continuation of insulin pump intraoperatively should be restricted to procedures of fewer than 2 hours duration; at the discretion of the anesthesiologist. Insulin pumps provide basal coverage with a continuous subcutaneous infusion of small doses of rapid-acting insulin. Nutritional and correctional bolus coverage is achieved by manually pushing a button to dispense the required amount of rapid-acting insulin. If not feasible to continue the pump, these patients should transition to a subcutaneous basal-bolus regimen. It is recommended to administer the basal insulin at least 2 hours before discontinuation of the insulin pump. This crucial step will prevent any lapse in basal insulin supply and subsequent rebound hyperglycemia or metabolic decompensation. The dose of long-acting basal insulin to be administered is equivalent to the 24-hour basal dose of insulin delivered by the pump. An alternative method is to calculate the basal requirement based on weight considering individual insulin sensitivity.[40]

Enteral Nutrition

Diabetic patients on enteral nutrition should preferably receive formulas containing low carbohydrates, high mono-saturated fatty acids, and subcutaneous insulin regimen should include basal, nutritional and correctional components. Usually, 30 to 50% of TDD is administered as basal insulin, once or twice daily. The remaining 50 to 70% of TDD is added as nutritional insulin.  An alternative method for calculating the dose of nutritional insulin is to administer 1 unit of rapid-acting or regular insulin for every 10 to 15 gram of carbohydrates that will be provided with each bolus feed or in 24 hours with a continuous feed.[34][41][42] In patients receiving continuous tube feeds, nutritional and correctional insulin is administered every 4 hours (with rapid-acting insulin) or every 6 hours (with regular insulin) while those receiving bolus enteral feeds, the nutritional and correctional insulin is given before the bolus feed.

Parenteral Nutrition

In patients receiving total parenteral nutrition (TPN), insulin can be provided either as a separate intravenous infusion or added to the TPN solution. When added to the solution, a starting point is to add 1 unit of regular insulin for every 10 grams of dextrose and the regimen adjusted every 1 to 2 days based on glycemic trends. Another method is to start a separate intravenous infusion initially, and once BG is within the glycemic goal, 80 to 100% of the total insulin dose provided via infusion is added to the TPN solution. Additionally, BG monitoring with subcutaneous correctional insulin every 4 to 6 hours is used to treat any hyperglycemia above the target range [34][43].  

Hypoglycemia

Based on the classification by International Hypoglycemia Study Group – BG less than 70 mg/dl is the hypoglycemia alert value (level 1), BG level less than 54 mg/dl indicates clinically significant hypoglycemia (level 2) and cognitive impairment with no specific BG threshold qualifies as severe hypoglycemia (level 3).[44] Iatrogenic hypoglycemia is the most dangerous adverse effect of antihyperglycemic therapy and is a major limiting factor in optimizing glycemic management in diabetic patients.

Iatrogenic hypoglycemia is a common occurrence in the perioperative setting and correlates to poor patient outcomes and mortality.[37][45] Inappropriately dosed insulin, aggressive glycemic target, insulin administration not aligned with meal-time, insulin stacking, unforeseen changes in caloric intake, poor provider-provider or provider-nurse communication, failure to recognize glycemic trends or intervene are a few factors that risk hypoglycemia.[46] Every institution should implement a hypoglycemia management protocol that entails a plan for both the prevention and treatment of hypoglycemia.[47] Per ADA recommendations, treatment regimen should be reviewed and if necessary changed when BG lower than 70 mg/dl is noted, as this usually precedes imminent severe hypoglycemia.

Enhancing Healthcare Team Outcomes

Interprofessional communication and care coordination amongst physicians (surgeons, anesthesiologists, hospitalists, endocrinologists, primary care provider), nurses, pharmacists, nutritionists & diabetes educator play a vital role in the optimal management of diabetes in the perioperative period, minimizes adverse events, improves clinical outcomes, and patient satisfaction. It is essential to formulate a structured plan, tailored to individual patient needs. Implementation of standardized protocols and computerized algorithms by hospitals is instrumental in reducing errors and providing quality care.[48] Patient or family should always receive both written and verbal instruction regarding changes in medication regimen pre- and postoperatively. 

A safe transition from inpatient to outpatient setting is a crucial component of diabetes management. The discharge plan should include medication reconciliation, patient education with a doctor, pharmacist, or nurse with specialty training in diabetes education, an evaluation of socioeconomic issues, and communication with an outpatient provider. Should the pharmacist have concerns after the medication reconciliation, it should be addressed with the team. The nurse diabetic educator should make sure both the patient and family understand the outpatient management plan. Again, if there are concerns over the potential lack of understanding or followup, it should be reported to the interprofessional team and addressed. A follow-up visit with the primary care provider or endocrinologist within one month of discharge is advisable for all patients. An earlier appointment within 1 to 2 weeks is preferred if there has been a change in medications, or glycemic control is not optimal at the time of discharge. Patients should receive prescriptions, drugs, and necessary medical equipment to help bridge care with their outpatient follow-up visit.[34]


  • Image 9837 Not availableImage 9837 Not available
    Contributed by Prerna Dogra, MD
Attributed To: Contributed by Prerna Dogra, MD

Interested in Participating?

We are looking for contributors to author, edit, and peer review our vast library of review articles and multiple choice questions. In as little as 2-3 hours you can make a significant contribution to your specialty. In return for a small amount of your time, you will receive free access to all content and you will be published as an author or editor in eBooks, apps, online CME/CE activities, and an online Learning Management System for students, teachers, and program directors that allows access to review materials in over 500 specialties.

Improve Content - Become an Author or Editor

This is an academic project designed to provide inexpensive peer-reviewed Apps, eBooks, and very soon an online CME/CE system to help students identify weaknesses and improve knowledge. We would like you to consider being an author or editor. Please click here to learn more. Thank you for you for your interest, the StatPearls Publishing Editorial Team.

Diabetic Perioperative Management - Questions

Take a quiz of the questions on this article.

Take Quiz
A 30-year old male is admitted to the hospital for surgery scheduled the next day. He has type 1 diabetes mellitus that is managed with a subcutaneous insulin pump (continuous subcutaneous insulin infusion) at home. The patient has removed his insulin pump in accordance with hospital policy. However, he is unable to recall his basal infusion rate. His current finger stick blood glucose is 130 mg/dL, and preoperative hemoglobin A1c is 6.5%. His body mass index is 20 kg/m2. Which of the following is the next best step in the management of this patient?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up

Diabetic Perioperative Management - References

References

Kotagal M,Symons RG,Hirsch IB,Umpierrez GE,Dellinger EP,Farrokhi ET,Flum DR, Perioperative hyperglycemia and risk of adverse events among patients with and without diabetes. Annals of surgery. 2015 Jan;     [PubMed]
Frisch A,Chandra P,Smiley D,Peng L,Rizzo M,Gatcliffe C,Hudson M,Mendoza J,Johnson R,Lin E,Umpierrez GE, Prevalence and clinical outcome of hyperglycemia in the perioperative period in noncardiac surgery. Diabetes care. 2010 Aug;     [PubMed]
Umpierrez GE,Isaacs SD,Bazargan N,You X,Thaler LM,Kitabchi AE, Hyperglycemia: an independent marker of in-hospital mortality in patients with undiagnosed diabetes. The Journal of clinical endocrinology and metabolism. 2002 Mar;     [PubMed]
Kwon S,Thompson R,Dellinger P,Yanez D,Farrohki E,Flum D, Importance of perioperative glycemic control in general surgery: a report from the Surgical Care and Outcomes Assessment Program. Annals of surgery. 2013 Jan;     [PubMed]
Umpierrez G,Cardona S,Pasquel F,Jacobs S,Peng L,Unigwe M,Newton CA,Smiley-Byrd D,Vellanki P,Halkos M,Puskas JD,Guyton RA,Thourani VH, Randomized Controlled Trial of Intensive Versus Conservative Glucose Control in Patients Undergoing Coronary Artery Bypass Graft Surgery: GLUCO-CABG Trial. Diabetes care. 2015 Sep;     [PubMed]
Schmeltz LR,DeSantis AJ,Thiyagarajan V,Schmidt K,O'Shea-Mahler E,Johnson D,Henske J,McCarthy PM,Gleason TG,McGee EC,Molitch ME, Reduction of surgical mortality and morbidity in diabetic patients undergoing cardiac surgery with a combined intravenous and subcutaneous insulin glucose management strategy. Diabetes care. 2007 Apr;     [PubMed]
Palermo NE,Gianchandani RY,McDonnell ME,Alexanian SM, Stress Hyperglycemia During Surgery and Anesthesia: Pathogenesis and Clinical Implications. Current diabetes reports. 2016 Mar;     [PubMed]
Lipshutz AK,Gropper MA, Perioperative glycemic control: an evidence-based review. Anesthesiology. 2009 Feb;     [PubMed]
Gottschalk A,Rink B,Smektala R,Piontek A,Ellger B,Gottschalk A, Spinal anesthesia protects against perioperative hyperglycemia in patients undergoing hip arthroplasty. Journal of clinical anesthesia. 2014 Sep;     [PubMed]
Clarke RS, The hyperglycaemic response to different types of surgery and anaesthesia. British journal of anaesthesia. 1970 Jan;     [PubMed]
Thorell A,Efendic S,Gutniak M,Häggmark T,Ljungqvist O, Insulin resistance after abdominal surgery. The British journal of surgery. 1994 Jan;     [PubMed]
Wiener RS,Wiener DC,Larson RJ, Benefits and risks of tight glucose control in critically ill adults: a meta-analysis. JAMA. 2008 Aug 27;     [PubMed]
Finfer S,Chittock DR,Su SY,Blair D,Foster D,Dhingra V,Bellomo R,Cook D,Dodek P,Henderson WR,Hébert PC,Heritier S,Heyland DK,McArthur C,McDonald E,Mitchell I,Myburgh JA,Norton R,Potter J,Robinson BG,Ronco JJ, Intensive versus conventional glucose control in critically ill patients. The New England journal of medicine. 2009 Mar 26;     [PubMed]
Griesdale DE,de Souza RJ,van Dam RM,Heyland DK,Cook DJ,Malhotra A,Dhaliwal R,Henderson WR,Chittock DR,Finfer S,Talmor D, Intensive insulin therapy and mortality among critically ill patients: a meta-analysis including NICE-SUGAR study data. CMAJ : Canadian Medical Association journal = journal de l'Association medicale canadienne. 2009 Apr 14;     [PubMed]
14. Diabetes Care in the Hospital: {i}Standards of Medical Care in Diabetes-2018{/i}. Diabetes care. 2018 Jan;     [PubMed]
Underwood P,Askari R,Hurwitz S,Chamarthi B,Garg R, Preoperative A1C and clinical outcomes in patients with diabetes undergoing major noncardiac surgical procedures. Diabetes care. 2014;     [PubMed]
Godshaw BM,Ojard CA,Adams TM,Chimento GF,Mohammed A,Waddell BS, Preoperative Glycemic Control Predicts Perioperative Serum Glucose Levels in Patients Undergoing Total Joint Arthroplasty. The Journal of arthroplasty. 2018 Jul;     [PubMed]
van den Boom W,Schroeder RA,Manning MW,Setji TL,Fiestan GO,Dunson DB, Effect of A1C and Glucose on Postoperative Mortality in Noncardiac and Cardiac Surgeries. Diabetes care. 2018 Apr;     [PubMed]
Halkos ME,Puskas JD,Lattouf OM,Kilgo P,Kerendi F,Song HK,Guyton RA,Thourani VH, Elevated preoperative hemoglobin A1c level is predictive of adverse events after coronary artery bypass surgery. The Journal of thoracic and cardiovascular surgery. 2008 Sep;     [PubMed]
Bardia A,Khabbaz K,Mueller A,Mathur P,Novack V,Talmor D,Subramaniam B, The Association Between Preoperative Hemoglobin A1C and Postoperative Glycemic Variability on 30-Day Major Adverse Outcomes Following Isolated Cardiac Valvular Surgery. Anesthesia and analgesia. 2017 Jan;     [PubMed]
Patoulias D,Manafis A,Mitas C,Avranas K,Lales G,Zografou I,Sambanis C,Karagiannis A, Sodium-glucose Cotransporter 2 Inhibitors and the Risk of Diabetic Ketoacidosis; from Pathophysiology to Clinical Practice. Cardiovascular     [PubMed]
Pasquel FJ,Gianchandani R,Rubin DJ,Dungan KM,Anzola I,Gomez PC,Peng L,Hodish I,Bodnar T,Wesorick D,Balakrishnan V,Osei K,Umpierrez GE, Efficacy of sitagliptin for the hospital management of general medicine and surgery patients with type 2 diabetes (Sita-Hospital): a multicentre, prospective, open-label, non-inferiority randomised trial. The lancet. Diabetes     [PubMed]
Hulst AH,Plummer MP,Hollmann MW,DeVries JH,Preckel B,Deane AM,Hermanides J, Systematic review of incretin therapy during peri-operative and intensive care. Critical care (London, England). 2018 Nov 14;     [PubMed]
Rushakoff RJ, Inpatient Diabetes Management 2000;     [PubMed]
Umpierrez GE,Smiley D,Zisman A,Prieto LM,Palacio A,Ceron M,Puig A,Mejia R, Randomized study of basal-bolus insulin therapy in the inpatient management of patients with type 2 diabetes (RABBIT 2 trial). Diabetes care. 2007 Sep;     [PubMed]
Umpierrez GE,Smiley D,Jacobs S,Peng L,Temponi A,Mulligan P,Umpierrez D,Newton C,Olson D,Rizzo M, Randomized study of basal-bolus insulin therapy in the inpatient management of patients with type 2 diabetes undergoing general surgery (RABBIT 2 surgery). Diabetes care. 2011 Feb;     [PubMed]
Duggan EW,Carlson K,Umpierrez GE, Perioperative Hyperglycemia Management: An Update. Anesthesiology. 2017 Mar;     [PubMed]
Bardia A,Wai M,Fontes ML, Sodium-glucose cotransporter-2 inhibitors: an overview and perioperative implications. Current opinion in anaesthesiology. 2019 Feb;     [PubMed]
Wesorick D,O'Malley C,Rushakoff R,Larsen K,Magee M, Management of diabetes and hyperglycemia in the hospital: a practical guide to subcutaneous insulin use in the non-critically ill, adult patient. Journal of hospital medicine. 2008 Sep;     [PubMed]
Ramos P,Childers D,Maynard G,Box K,Namba J,Stadalman K,Renvall M, Maintaining glycemic control when transitioning from infusion insulin: a protocol-driven, multidisciplinary approach. Journal of hospital medicine. 2010 Oct;     [PubMed]
Schmeltz LR,DeSantis AJ,Schmidt K,O'Shea-Mahler E,Rhee C,Brandt S,Peterson S,Molitch ME, Conversion of intravenous insulin infusions to subcutaneously administered insulin glargine in patients with hyperglycemia. Endocrine practice : official journal of the American College of Endocrinology and the American Association of Clinical Endocrinologists. 2006 Nov-Dec;     [PubMed]
Garg R,Schuman B,Hurwitz S,Metzger C,Bhandari S, Safety and efficacy of saxagliptin for glycemic control in non-critically ill hospitalized patients. BMJ open diabetes research     [PubMed]
Umpierrez GE,Gianchandani R,Smiley D,Jacobs S,Wesorick DH,Newton C,Farrokhi F,Peng L,Reyes D,Lathkar-Pradhan S,Pasquel F, Safety and efficacy of sitagliptin therapy for the inpatient management of general medicine and surgery patients with type 2 diabetes: a pilot, randomized, controlled study. Diabetes care. 2013 Nov;     [PubMed]
Bellido V,Suarez L,Rodriguez MG,Sanchez C,Dieguez M,Riestra M,Casal F,Delgado E,Menendez E,Umpierrez GE, Comparison of Basal-Bolus and Premixed Insulin Regimens in Hospitalized Patients With Type 2 Diabetes. Diabetes care. 2015 Dec;     [PubMed]
Umpierrez GE,Smiley D,Hermayer K,Khan A,Olson DE,Newton C,Jacobs S,Rizzo M,Peng L,Reyes D,Pinzon I,Fereira ME,Hunt V,Gore A,Toyoshima MT,Fonseca VA, Randomized study comparing a Basal-bolus with a basal plus correction insulin regimen for the hospital management of medical and surgical patients with type 2 diabetes: basal plus trial. Diabetes care. 2013 Aug;     [PubMed]
Demma LJ,Carlson KT,Duggan EW,Morrow JG 3rd,Umpierrez G, Effect of basal insulin dosage on blood glucose concentration in ambulatory surgery patients with type 2 diabetes. Journal of clinical anesthesia. 2017 Feb;     [PubMed]
Umpierrez GE, Basal versus sliding-scale regular insulin in hospitalized patients with hyperglycemia during enteral nutrition therapy. Diabetes care. 2009 Apr;     [PubMed]
Elia M,Ceriello A,Laube H,Sinclair AJ,Engfer M,Stratton RJ, Enteral nutritional support and use of diabetes-specific formulas for patients with diabetes: a systematic review and meta-analysis. Diabetes care. 2005 Sep;     [PubMed]
Pichardo-Lowden AR,Fan CY,Gabbay RA, Management of hyperglycemia in the non-intensive care patient: featuring subcutaneous insulin protocols. Endocrine practice : official journal of the American College of Endocrinology and the American Association of Clinical Endocrinologists. 2011 Mar-Apr;     [PubMed]
Jacobi J,Bircher N,Krinsley J,Agus M,Braithwaite SS,Deutschman C,Freire AX,Geehan D,Kohl B,Nasraway SA,Rigby M,Sands K,Schallom L,Taylor B,Umpierrez G,Mazuski J,Schunemann H, Guidelines for the use of an insulin infusion for the management of hyperglycemia in critically ill patients. Critical care medicine. 2012 Dec;     [PubMed]
Partridge H,Perkins B,Mathieu S,Nicholls A,Adeniji K, Clinical recommendations in the management of the patient with type 1 diabetes on insulin pump therapy in the perioperative period: a primer for the anaesthetist. British journal of anaesthesia. 2016 Jan;     [PubMed]
Lansang MC,Modic MB,Sauvey R,Lock P,Ross D,Combs P,Kennedy L, Approach to the adult hospitalized patient on an insulin pump. Journal of hospital medicine. 2013 Dec;     [PubMed]
Evans K, Insulin pumps in hospital: a guide for the generalist physician. Clinical medicine (London, England). 2013 Jun;     [PubMed]
Kulasa K,Juang P, How Low Can You Go? Reducing Rates of Hypoglycemia in the Non-critical Care Hospital Setting. Current diabetes reports. 2017 Sep;     [PubMed]
Mustafa OG,Choudhary P, Hypoglycaemia in hospital: a preventable killer? Diabetic medicine : a journal of the British Diabetic Association. 2014 Oct;     [PubMed]
Glucose Concentrations of Less Than 3.0 mmol/L (54 mg/dL) Should Be Reported in Clinical Trials: A Joint Position Statement of the American Diabetes Association and the European Association for the Study of Diabetes. Diabetes care. 2017 Jan;     [PubMed]
Devanesan A,Lloyd J,Samad H,Saha S, Glycaemic control in intensive care: Everything in moderation. Journal of the Intensive Care Society. 2016 Nov;     [PubMed]
Draznin B,Gilden J,Golden SH,Inzucchi SE,Baldwin D,Bode BW,Boord JB,Braithwaite SS,Cagliero E,Dungan KM,Falciglia M,Figaro MK,Hirsch IB,Klonoff D,Korytkowski MT,Kosiborod M,Lien LF,Magee MF,Masharani U,Maynard G,McDonnell ME,Moghissi ES,Rasouli N,Rubin DJ,Rushakoff RJ,Sadhu AR,Schwartz S,Seley JJ,Umpierrez GE,Vigersky RA,Low CC,Wexler DJ, Pathways to quality inpatient management of hyperglycemia and diabetes: a call to action. Diabetes care. 2013 Jul;     [PubMed]

Disclaimer

The intent of StatPearls is to provide practice questions and explanations to assist you in identifying and resolving knowledge deficits. These questions and explanations are not intended to be a source of the knowledge base of all of medicine, nor is it intended to be a board or certification review of CNS-Adult Health. The authors or editors do not warrant the information is complete or accurate. The reader is encouraged to verify each answer and explanation in several references. All drug indications and dosages should be verified before administration.

StatPearls offers the most comprehensive database of free multiple-choice questions with explanations and short review chapters ever developed. This system helps physicians, medical students, dentists, nurses, pharmacists, and allied health professionals identify education deficits and learn new concepts. StatPearls is not a board or certification review system for CNS-Adult Health, it is a learning system that you can use to help improve your knowledge base of medicine for life-long learning. StatPearls will help you identify your weaknesses so that when you are ready to study for a board or certification exam in CNS-Adult Health, you will already be prepared.

Our content is updated continuously through a multi-step peer review process that will help you be prepared and review for a thorough knowledge of CNS-Adult Health. When it is time for the CNS-Adult Health board and certification exam, you will already be ready. Besides online study quizzes, we also publish our peer-reviewed content in eBooks and mobile Apps. We also offer inexpensive CME/CE, so our content can be used to attain education credits while you study CNS-Adult Health.