Leeds Teaching Hospitals Guidelines for the management of adults with diabetes undergoing surgery or elective procedures

1. Guidance for perioperative management of non insulin hypoglycaemic agents and insulin
2. Guidance on the management of hyper and hypo glycaemia pre & postoperatively in adult patents undergoing elective day surgery 
3. Variable rate intravenous insulin infusion (VRIII) prescription chart for adults’ patients undergoing surgery/invasive procedures

At LTHT we have adopted, with a few variations, the relevant Joint British Diabetes Societies (JBDS) National Guideline. When using the national guideline please be sure to refer to these variations. The variations are listed here using the headings in the national guideline.

The JBDS guideline is available at this link:
https://www.diabetes.org.uk/resources-s3/2017-09/Surgical guideline 2015 - summary FINAL amended Mar 2016.pdf

Main Recommendations (page 7)

• Point 10
  At present, at LTHT we follow the Enhanced Recovery Partnership Programme except we don’t give carbohydrate preload to people with diabetes. This is to reduce risk of upsetting glucose control, and also in view of possible delayed gastric emptying in people with diabetes.

• Point 19
  At LTHT our aims are to minimise use of VRIII pre-operatively and also to minimise cancellation of patients due to their diabetes. To avoid unnecessary use of VRIII, we should ensure that each patient with diabetes misses no more than one meal.  In practical terms this means these patients must be prioritised for bed allocation.
  Where this is not going to be possible, then early communication with anaesthetist, surgeon and bed managing team should occur. This is to enable best decision for each individual patient to balance patient safety with unnecessary cancellations. 
  The outcome of this discussion should be documented. In some exceptional circumstances the decision will be to proceed to surgery despite two missed meals.
  If the patient’s procedure is cancelled then a Datix should be completed and sent to the Clinical Governance Lead for Anaesthesia Dr Indu Sivanandan.
  Patients on lifestyle alone or once daily metformin, where their capillary blood glucose in preoperative period exceeds 12 mmol/L on more than 2 occasions should be discussed with the anaesthetist in the first instance.  This is because it may be appropriate to proceed without starting VRIII in some circumstances where this is considered less risky overall. This is in line with established practice at LTHT.

• Point 20
  At LTHT, if a VRIII is required then  the recommended substrate IV fluid of choice is 0.18% Sodium Chloride/4% glucose with either  0.15% or 0.3% potassium chloride as appropriate. This is because 0.45%NaCl/5% glucose is not routinely available.

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Guidelines for peri-operative diabetes care

• Use of oral carbohydrate loading (page 17):
  At LTHT we don’t recommend oral carbohydrate loading as part of the enhanced recovery partnership program for people with diabetes.  This is in line with established practice at LTHT

Pre-operative assessment

• Recommendation 2b (page 22)
  At LTHT the following patients in pre-assessment should be discussed with the Diabetes In-patient Specialist Team

• Recommendation 2d VI (page 22)
  At LTHT we don’t recommend oral carbohydrate loading as part of the enhanced recovery partnership program for people with diabetes.  This is in line with established practice at LTHT.  Patients with diabetes are offered all other elements of the enhanced recovery partnership program.

• Recommendation 2h and 2i (pages 22 and 23): patients’ diabetes medicines and hypoglycaemia treatment
  At LTHT, due to the operation of the emedicines system, these are prescribed by the admitting team pre-operatively, when the patient attends hospital for their surgery (ie on the day case unit, admission lounge or admitting ward), and not in pre-assessment.

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Hospital admission

• Recommendation 6 (page 24)
  At LTHT, if a VRIII is required then  the recommended substrate IV fluid of choice is 0.18% Sodium Chloride/4% glucose with either  0.15% or 0.3% potassium chloride as appropriate. This is because 0.45%NaCl/5% glucose is not routinely available.

• Anticipated long starvation period (more than one missed meal) (page 25)
  At LTHT we comply with this recommendation but also note:
  • See page 7 point 19 comments above.
  • At LTHT we try to minimise initiation of VRIII pre-operatively.  We recommend intraoperative initiation of VRIII under direct supervision of the consultant anaesthetist.  This is to reduce risk
    
    
• Recommendations (Page 27).
  At LTHT, if a VRIII is required then  the recommended substrate IV fluid of choice is 0.18% Sodium Chloride/4% glucose with either  0.15% or 0.3% potassium chloride as appropriate. This is because 0.45%NaCl/5% glucose is not routinely available.

• Box 7 (page 32)
  At LTHT, if a VRIII is required then  the recommended substrate IV fluid of choice is 0.18% Sodium Chloride/4% glucose with either  0.15% or 0.3% potassium chloride as appropriate. This is because 0.45%NaCl/5% glucose is not routinely available.

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MHRA Alert Below  

SGLT2 inhibitors

This has in the following summary of advice for healthcare professionals:

• Interrupt sodium-glucose co-transporter 2 (SGLT2) inhibitor treatment in patients who are hospitalised for major surgical procedures or acute serious medical illnesses
• Monitor ketones during this period – measurement of blood ketone levels is preferred to urine
• Restart treatment with the SGLT2 inhibitor once ketone values are normal and the patient’s condition has stabilised.
• Report suspected adverse drug reactions to SGLT2 inhibitors to the Yellow Card Scheme )

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Appendix 1:  Guideline for peri-operative adjustment of insulin

• Recommendations in the table on pages 53 and 54.
  At LTHT, we use a document to guide patients and staff as to how to adjust insulin doses on the day before and day of surgery. This is completed as part of the pre-assessment visit.
  The advice has minor additions and differences from the recommendations in the JBDS Appendix 1 table. These are for consistency and clarity to improve safety.
  • The dose reduction for patients on ONLY ‘Twice daily intermediate/long acting insulin’ has been standardised to 80% of normal dose day before surgery. The guidance for twice a day basal insulin is not specifically specified in JBDS guidelines. However, it is in line with the standard recommendation to give 80% of basal insulin for patients on once a day basal insulin.
  • The dose reduction for patients on ‘Twice daily - separate injections of rapid / short-acting’ has been adjusted in order to make the calculation easier for both patients and health professionals.
  • The dose reduction of patient on continuous subcutaneous insulin pump (CSII) is recommended in certain circumstances where there is a higher risk for hypoglycaemia especially in patients with recurrent hypoglycaemia.

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Appendix 4: Guideline for peri-operative monitoring of diabetes and management of hyperglycaemia and hypoglycaemia in patients undergoing surgery with a short starvation period (one missed meal)

• Management of hyperglycaemia (blood glucose greater than 12 mmol/L… pages 59 and 59)
  The management for hyperglycaemia has been standardised for both type 1 and type 2 diabetes patients. This means the dose of insulin to be used will depend on the blood glucose measurement for both people with type 1 and those with type 2 diabetes. The use of weight-based insulin correction (for type 2 diabetes) is felt to be too complicated and so introduce needless risk of miscalculation.

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