There seems to be a of variety of viewpoints regarding the perioperative management of glucose levels in the diabetic surgical patient. There is no gold standard with regard to the management of these patients, and any protocols which exist appear to originate based upon the particular dogma of the anesthesia department at the facility in question.

Numerous studies have demonstrated that anti-hyperglycemic therapies meant to maintain patients' blood glucose levels at or below 110mg/dL are associated with an improved clinical outcomes. Certainly it has been established that a blood glucose of persistantly greater than 200mg/dL has been shown to have adverse cardiovascular and immunologic effects. The question remains "How do we get there?" Perhaps the most successful strategy in the perioperative management of glucose levels in patients with diabetes would be an algorithm that most completely simulates normal physical response. Further, evidenced-based studies need to be done to determine an appropriate protocol.


I would imagine that there are global similarities between the various protocols for the management of hyperglycemia perioperatively, but I am curious as to what differences in protocols may exist, and the reasoning behind these differences. For example, I have worked at two hospitals owned by the same parent organization, but at one hospital anesthesia prefers that non-ESRD diabetic patients be given intravenous fluids that include dextrose perioperatively while at the other hospital, anesthesia seems to prefer the non-ESRD diabetic patients be given 1/2 normal saline and no dextrose. These hospitals stand five miles apart yet have vastly different management protocols, and upon questioning, each hospitals anesthesiologist can present anecdotal evidence and literature to support the protocol.


What protocols do you follow based upon your training and the specific dogma of the anesthesia departments that you interact with throughout the course of your surgical practice?

Hi Ryan,
Thank you for this poignant observation. Turns out that the data on tight INTRAoperative glycemic control is not nearly as good as the data on tight POSToperative glycemic control in surgical patients. One can speculate that this has to do with the duration that patients spend in the OR vs. the SICU. As for protocols, I am not sure if our anesthesiolopgists at Mount Sinai are using a protocol or not, but our deep sternal wound infections in the surgical ICU have gone from 14 in 6 months to 1 in 6 months once tight control was initiated. Not bad, eh?

Hey Ryan,
When I was on my anesthesia rotation, it was recommended to me that I order 1/2 NS @ 75 ml/hr to begin the morning of surgery for our in-house diabetic patients who do not have end stage renal disease. For those patients with ESRD on HD, anesthesia at my facility recommends no continuous fluid pre-operatively. However, depending on their fluid status, they sometimes give a small amount of plain NS. Post-operatively, rapid glucose checks in the PACU were also highly recommended.

It certainly seems that Sarah's anesthesia rotation is in line with Dr. Tamler's post that suggests that post-operative management of hyperglycemia is the key in terms of achieving successful outcomes. It would make sense that length of OR time and anticipated stress on the patient would affect one's choice of pre and intraop management of blood glucose, but certainly rapid glucose checks in pacu to establish tight glycemic control as is recomended in the literature.

I can tell you that we observe a clear clinical link between post opertative wound infection and dehiscense in patients who are poorly compliant to glucose control peri operatively.

yes it is very difficult once we allow oral diet.No surety of eating bec of pain,antibiotics, nausea, fever and with other co morbidities. Insulin analogues are the best with frequent monitoring and multiple doses or CGMS
and good controll with its help

I just stumbled upon this somewhat older post and found it interesting. I was trained in the early 90's and we were trained that pre-operatively we should keep them "sweet," i.e. in the  200-250 glucose range.

It was thought that if the blood sugar was up it was less harmful than if it went down (i.e. neural effects).

Question for you young "whippersnappers": Is it now thought that keeping them sweet for the period of the surgery is long enough to do enough damage to effect healing? Could that also predispose them to infection?

I, apparently, need to step up to the 21st century and need your help doing so! Thank you in advance. That is what Present is all about, after all!