Perioperative management of diabetes: translating evidence into practice

Glycemic control before, during, and after surgery reduces the risk of infectious complications; in critically ill surgical patients, intensive glycemic control may reduce mortality as well. The preoperative assessment is important in determining risk status and determining optimal management to avoid clinically significant hyper- or hypoglycemia. While patients with type 1 diabetes should receive insulin replacement at all times, regardless of nutritional status, those with type 2 diabetes may need to stop oral medications prior to surgery and might require insulin therapy to maintain blood glucose control. The glycemic target in the perioperative period needs to be clearly communicated so that proper insulin replacement, consisting of basal (long-acting), prandial (rapid-acting), and supplemental (rapid-acting) insulin can be implemented for optimal glycemic control. The postoperative transition to subcutaneous insulin, if needed, can begin 12 to 24 hours before discontinuing intravenous insulin, by reinitiation of basal insulin replacement. Basal/bolus insulin regimens are safer and more effective in hospitalized patients than supplemental-scale regular insulin.