10. Peri-operative care — ITSDIABETES ITS Inpatient Diabetes Training & Support

Introduction

Hyperglycaemia in people undergoing surgery is associated with post-operative harm. These harms include post-operative infections, acute kidney injury, acute myocardial infarction or death. Patients with diabetes have longer lengths of stay and are less likely to be admitted on the day of surgery.

This section aims to provide guidance to improve standards of care and outcomes for people with diabetes undergoing operative or investigative procedures requiring a period of starvation.

The guidance is primarily intended for the management of patients with diabetes referred for elective surgery. However, most of the recommendations can be applied to the patient presenting for emergency surgery with the proviso that many such patients are high risk and are likely to require an intravenous insulin infusion and care on an acute ward with possible input from critical care team.

Management of adult patient with diabetes undergoing surgery and fasted procedures UHL adult guideline

Key safety messages:

For elective surgery aim to optimize diabetes control with prior to surgery with target HbA1c of 8.5% or <69mmol/mol.
Patients should have a peri-operative care plan in place which has been agreed at pre-assessment. Consider carefully which diabetes medication should be continued during the peri-operative period and which requires stopping. Most elective cases can be managed by manipulating usual diabetes treatment.
Pre-prescribe hypoglycaemia treatment for all patients
Peri-operative capillary blood glucose (CBG) targets are 6-10mmol/l for patients who are asleep (up to 12mmol/l acceptable), 6-10mmol/l (4-12mmol/l acceptable) for patients who are awake.
Emergency admissions are likely to require variable rate intravenous insulin infusion during the peri-operative period. Glucose containing substrate fluids must be prescribed alongside the iv insulin to avoid hypoglycaemia – refer to local guidance.
Long acting insulin analogues should be continued during peri-operative period. Reduce dose by 20% until patient eating normally.
Transfers between areas (eg, theatre to ward, ITU to ward) can be high risk times and special attention should be made in planning and monitoring before, during and after transfer. NEVER disconnect or stop insulin for patients with type 1 diabetes transferring between clinical areas – risk of DKA
Minimise post-operative nausea and vomiting to allow rapid resumption of eating and drinking.
Aim to resume eating and drinking ASAP and therefore resume usual diabetes treatment.
Patients with prolonged periods of fasting, sepsis or complications should be referred to the specialist diabetes team for input and advice on management.

The JBDS has published a comprehensive guidance on the Management of Adults with diabetes undergoing surgery. This document outlines a clear pathway from primary care referral, through the peri-operative period to discharge.

Pathway from primary care referral, through the peri-operative period to discharge.

ITS ANIMATION: Peri-op CARE and Diabetes

NCEPOD report: High and Lows: Peri-operative diabetes (2018)

This NCEPOD report highlights the quality of diabetes care for patients aged 16 years or older who underwent a surgical procedure. The report takes a critical look at areas where the care of patients might have been improved.

Key findings

Lack of clinical continuity of diabetes management across the different specialties in the perioperative pathway.
Absence of joint ownership of the diabetes meant that the diabetes management of the patient was falling between gaps in the surgical pathway.
Under involvement of key diabetes team members such as diabetes specialist nurses, dietitians and pharmacists.
Nutritional assessments and medicine reconciliations were frequently not undertaken
The management plan for a patient with diabetes undergoing surgery should include their prioritisation on the operating list. This study found that 9.6% (42/439) of patients were not prioritised appropriately, which subjected them to prolonged fasting, putting them at increased risk of complications.
Regular monitoring of blood glucose was under-utilised pre- intra- and post-operatively.
Overall the report highlighted that there was room for improvement in the clinical care of 35.8% (182/509) of patients in the study. This percentage was similar to that of good practice which was found in 34.8% (177/509) of patients.

Twelve key recommendations were made which can be found in the full report (see NCEPOD report ). These recommendations should form the focus of action for hospital trusts. However as a HCP caring for a patient with diabetes undergoing surgery an awareness of current guidance and potential gaps in care provision will allow you to focus on providing the best possible care.