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REVIEW
SA JOURNAL OF DIABETES & VASCULAR DISEASE
54
VOLUME 9 NUMBER 2 • JUNE 2012
are not particularly ill and are likely to be eating normally. These
agents can be restarted prior to discharge once it is clear that the
patient is recovering and will be ready for discharge soon.
Metformin: this should be discontinued in anticipation of
•
contra-indications to its use, which may be likely to arise in
the peri-operative period. These include renal failure, unstable
haemodynamics and the need for an imaging study, which will
require contrast.
Sulphonylureas: there are no safety data and the risk of prolonged
•
hypoglycaemia in unstable patients who may not be eating is
significant. It should be discontinued and only re-initiated once
it is clear that the patient is stable, eating normally and is nearly
ready for discharge.
Thiazolidinediones are no longer considered to be safe
•
hypoglycaemic agents, even in the outpatient setting and should
be discontinued in the peri-operative period. Upon discharge,
an alternative agent should be considered.
DDP4 inhibitors: there are no safety data and they should be
•
discontinued. Particular care should be taken with vildagliptin
with renal impairment. It should only be restarted once the
patient is stable, eating normally, is almost ready for discharge
and renal function has been determined to be normal.
GLP1 analogues: there are no safety data and these should be
•
discontinued until the patient is stable, eating normally and
nearing discharge.
Healthcare specialist’s roles in the peri-operative period
Diabetes management may be under the care of the patient’s
general practitioner, a physician, an endocrinologist, the surgeon
or the anaesthetist, depending on the circumstances and levels of
experience. However, the use of appropriately trained specialists
such as endocrinologists has been shown to reduce the length of
stay, improve glycaemic control and improve outcomes.
3
Where
available, their involvement should be sought for management of
all diabetics in the hospital setting and especially the peri-operative
period.
The patient’s role in the peri-operative period
Patients who are fully conscious, well educated in diabetes
care and have stable pre-operative glucose profiles should be
encouraged to participate in the management of their diabetes
in this period. Involvement may range from self monitoring of
blood glucose and carbohydrate consumption to assuming full
responsibility for their insulin treatment under the guidance of
the healthcare team.
Planning discharge
This is not as simple as just sending the patient home and telling
him/her to restart the usual medication. There are some very
important points which need to be considered and guidelines to
be adhered to:
Care must be taken to be sure that the diabetic has stable
•
glycaemic control on treatment that can be continued safely
at home.
If the patient is newly diagnosed or there has been significant
•
change to the pre-admission treatment, care must be taken
to ensure the patient understands the changes. This may not
be appropriate for the surgeon to do and an endocrinologist
consultation may be required.
If required, consider:
•
– dietician consultation to educate and plan the post-operative
diet if significant changes are required.
– diabetic educator if newly diagnosed or significant changes
to medication or complications of diabetes have been
detected.
A discharge summary should be sent to the healthcare
•
professional usually responsible for the patient’s diabetes care.
A follow-up appointment should be made with the healthcare
•
professional responsible for the diabetes care, to ensure
glycaemic control remains stable and to ensure compliance and
adherence to treatment, especially if significant changes have
been made.
Conclusion
There are a number of important factors to be considered and
guidelines that need to be in place to ensure optimal care of
patients in the peri-operative period. This will result in optimal
outcomes. Most important is identification of the patient as a
diabetic, and then planning treatment of the diabetes in the peri-
operative period.
Other than in exceptional circumstances, most anti-diabetic
agents, except insulin, should be discontinued. For patients not
on insulin already, an appropriate regime should be planned. The
use of sliding-scale insulin regimes should never be used for longer
than a few hours and ideally all patients should be started on an
appropriate basal–bolus regime with allowance made for corrective
doses if needed.
Glycaemic control should not be too tight in the majority
of patients, with a range of 6.1–10 mmol/l considered most
appropriate for most patients. Hypoglycaemia should be avoided
as it appears that this is linked to increased mortality. Appropriately
trained specialists such as endocrinologists should be involved
whenever possible. Appropriate education and understanding
should be ensured and careful follow up and monitoring arranged
prior to discharge.
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