Title of Guideline (must include the word Guideline (not protocol, policy, procedure etc) Contact Name and Job Title (author) Directorate & Speciality Guideline for the management of adults with diabetes undergoing surgery and elective procedures Dr Simon Page Consultant, Diabetes & Endocrinology Acute Medicine Directorate Date of submission 14/08/2013 Updated August 2017 Date on which guideline must be reviewed (this should be one to three years) Explicit definition of patient group to which it applies (e.g. inclusion and exclusion criteria, diagnosis) 14/08/2020 This guideline includes: Adults with diabetes Short starvation (daycase) surgery Extended starvation (inpatient) surgery Version 6.0 Abstract Exclusion: Variable Rate Insulin Infusion (VRII) in critical care/high dependency; see separate guidelines from critical care Paediatrics This guideline describes the management of adult patients with diabetes undergoing day surgery on short starvation (less than 12 hours without a meal missing only one meal) and extended starvation regimens (more than 12 hours without a meal missing 2 meals or more) as inpatients for surgery. Page 1 of 21
Key Words Statement of the evidence base of the guideline has the guideline been peer reviewed by colleagues? Evidence base: (1-6) 1 NICE Guidance, Royal College Guideline, SIGN (please state which source). 2a meta analysis of randomised controlled trials 2b at least one randomised controlled trial 3a at least one well-designed controlled study without 3b randomisation at least one other type of well-designed quasiexperimental study 4 well designed non-experimental descriptive studies (ie comparative / correlation and case studies) 5 expert committee reports or opinions and / or clinical experiences of respected authorities 6 recommended best practise based on the clinical experience of the guideline developer Consultation Process Target audience Adults with diabetes; short starvation; extended starvation; day surgery; inpatient surgery. These guidelines were peer reviewed by senior medical and nursing staff in the Diabetes unit and ratified at the TC CGRM committee. The guidelines have also been reviewed by colleagues external to Diabetes including Pharmaceutical, Renal and Surgical and Anaesthetics colleagues. Evidence base: No. 5 The guidelines are adapted from recommendations contained within: NHS Diabetes (2011) Management of adults with diabetes undergoing surgery and elective procedures: improving standards, available at: http://www.diabetes.nhs.uk/ areas_of_care/emergency_and_ inpatient/perioperative_management/ Barker et al., Association of Anaesthetists of Great Britain and Ireland Guidelines 2015. Anaesthesia 2015, p1-14 doi:10.1111/anae.13233. MHRA guidance on SGLT2 inhibitors available at: https://www.gov.uk/drugsafety-update/sglt2-inhibitors-updatedadvice-on-the-risk-of-diabetic-ketoacidosis These guidelines were developed in conjunction with medical, nursing staff across the diabetes unit and pharmaceutical, renal, surgical and anaesthetics colleagues. NUH intranet, nursing, pharmacy & medical staff. This guideline has been registered with the trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt contact a senior colleague or expert. Caution is advised when using guidelines after the review date. Page 2 of 21
Contents Section Title Page number i) Front Sheet 1 ii) Front Sheet 2 iii) Contents 3 1 Diabetes and short starvation (Day case) surgery 4 assessment and management guidelines 2 Commonly used regimes 5 3 Day case (short starvation) non- medication 6 guidelines 4 Day case (short starvation) (1) 7 5 Day case (short starvation) (2) 8 6 Short starvation surgery admission guidance for 9 glucose assessment and management 7 Diabetes and extended starvation (inpatient) 10 surgery assessment and management guidelines 8 Inpatient surgery (extended starvation) non- 11 medication guidelines 9 Inpatient surgery (extended starvation) (1) 12 10 Inpatient surgery (extended starvation) (2) 13 11 Inpatient surgery (extended starvation) variable 14 rate intravenous infusion (VRII) 12 Transfer from VRII to usual diabetes medication 15 including 13 Hyperglycaemia and ketone testing pre- or postoperatively 16 14 NUH Patient information leaflet for patients 17 undergoing surgery or procedures requiring a period of starvation 15 Sick Day rules for people with diabetes 18 16 Patient discharge letter 19 17 Primary Care Input to Service: surgical referral 20 diabetes data fact sheet 18 Pre-operative assessment for diabetes 21 Page 3 of 21
Diabetes and Short Starvation (Day case) Surgery Assessment and Management Guidelines Short starvation means less than 12 hours without a meal missing one meal Adult patient with diabetes referred for surgery Elective procedure? NO If surgery urgent Seek diabetes team advice on supplemental Consider VRIII regimen Will the patient be nil by mouth (NBM) for < 12 hr (miss no more than 1 meal)? HBA1c within the last 3 months? NO Check HBA1c < 69 mmol/mol (8.5%) NO Refer to GP or diabetes team for stabilisation YES YES YES YES Surgical admission plan Day before surgery admission? Day of surgery admission with extended stay Daycase? Book patient for admission on pre-op day Book patient for day of surgery admission Book patient for day surgery Page 4 of 21
Commonly Used Insulin Regimens Twice daily (bd) regimen Injections given pre-breakfast and pre-evening meal. Twice daily medium acting (Insulatard, Humulin I, Insuman basal). Pre-mixed human (Humulin M3, Insuman Comb 15, 25 or 50). Pre-mixed analogue (Novomix30, Humalog Mix 25 or Mix 50). Three times daily (tds) regimen Breakfast pre-mix (e.g. Novomix 30, Humalog Mix 25 or Mix 50). PLUS Evening meal short acting (e.g. Actrapid, Humulin S, Insuman Rapid, Novorapid, Insulin Fiasp, Humalog, Apidra,). PLUS Bedtime medium/long acting (e.g. Insulatard, Humulin I, Insuman Basal, Levemir, Lantus). OR Three times daily pre-mix (e.g. Novomix 30, Humalog Mix 25 or Mix 50). Basal bolus (qds) regimen Basal given once or twice daily Typically twice daily: Insulatard, Humulin I,Insuman Basal Typically once daily: Lantus, Levemir, Degludec morning or evening time PLUS Bolus with each meal, in doses proportionate to intended carbohydrate intake Human soluble : Actrapid, Humulin S, Insuman Rapid or Human rapid acting analogue : Novorapid, Insulin Fiasp, Humalog, Apidra Page 5 of 21
Day case (short starvation) non- medication guidelines Tablet Alpha glucosidase inhibitor Acarbose Meglitinide Repaglinide Netaglinide Biguanide Metformin Day before admission Take as normal Take as normal Take as normal Day of surgery CHECK BLOOD SUGAR ON ADMISSION Morning procedure Omit MORNING dose if NBM Omit MORNING dose if NBM Give LUNCHTIME dose if recovered and eating Afternoon procedure Give MORNING dose if eating Omit LUNCHTIME dose if NBM Give MORNING dose if eating Omit LUNCHTIME dose Sulphonylurea Gliclazide Glipizide Glibenclamide Take as normal Once daily Omit MORNING dose Twice daily Omit MORNING dose Once daily Omit MORNING dose Twice daily Omit MORNING. Give EVENING dose if eating OMIT evening dose if not eating Glitazone Pioglitazone Take as normal DPP-IV inhibitor Sitagliptin Saxagliptin Linagliptin Vildagliptin Take as normal SGLT2 inhibitor* Dapagliflozin Canagloflozin Empagliflozin Take as normal Omit on day of surgery Omit on day of surgery GLP-1 analogue Exenatide Liraglutide Lixisenatide Take as normal * MRHA guidance 2016: interrupt treatment with the SGLT2 inhibitor in patients who are hospitalised for major surgery or acute serious illnesses; treatment may be restarted once the patient s condition has stabilised Page 6 of 21
Day case (short starvation) (1) Insulin regimen Once daily evening Human NPH eg Insulatard; Humulin I Insuman Human analogue eg Levemir, Lantus, Degludec Once daily morning Human NPH e.g. Insulatard; Humulin I; Insuman. Human analogue e.g. Levemir; Lantus, Degludec. Twice daily Human NPH e.g. Insulatard; Humulin I; Insuman. Human pre-mixed e.g. Humulin M3; Insuman Comb 25;Insuman Comb 50. Human analogue premix e.g. Novomix 30; Humalog Mix 25 or Mix 50. Human analogue e.g. Levemir; Lantus. Twice daily free mix short & intermediate Short acting: e.g. animal neutral; Actrapid; Humulin S; Insuman Rapid; Novorapid; Humalog; Apidra Intermediate acting: e.g. animal NPH; Insulatard; Humulin I; Insuman Basal. Day before surgery No change No change No change No change Day of surgery CHECK BLOOD SUGAR ON ADMISSION Morning procedure Not applicable No dose change but administer usual dose after procedure Morning Usual MORNING dose after procedure Evening Usual dose Morning Usual morning doses after procedure Evening Usual dose Afternoon procedure No dose change Administer usual dose at usual time No dose change Morning Half of usual MORNING dose Evening Usual dose Morning Half of total morning dose as INTERMEDIATE acting Evening Usual dose Page 7 of 21
Day case (short starvation) (2) Insulin regimen Day before surgery Day of surgery CHECK BLOOD SUGAR ON ADMISSION Morning procedure Afternoon procedure Three times daily premix Humulin M3, Insuman Comb 15, 25 or 50, Novomix 30, Humalog Mix 25 or Mix 50 Basal bolus Continuous Subcutaneous Insulin Infusion (CSII) pump No change Morning Usual MORNING dose after procedure Lunchtime Usual LUNCHTIME dose if eating OMIT if not eating Evening Usual EVENING dose No change Basal unchanged Morning Omit MORNING bolus Lunchtime Usual LUNCHTIME bolus if eating OMIT if not eating. Evening Usual EVENING dose(s) No change Basal unchanged Omit bolus doses while on VRIII Seek Diabetes Team advice Morning Half usual MORNING dose Lunchtime Omit LUNCHTIME dose Evening Usual EVENING dose if eating OMIT if not eating Basal unchanged Morning Usual MORNING bolus if eating OMIT if not eating Lunchtime Omit LUNCHTIME bolus. Evening Usual EVENING dose(s) Basal unchanged Omit bolus doses while on VRIII Seek Diabetes Team advice Page 8 of 21
Short starvation Surgery Admission Guidance for Glucose Assessment and Management Refer to and/or tablet guidance tables for information on management of diabetes therapies Check capillary blood glucose ON ARRIVAL on ALL patients Fasting gluose < 4 mmol/l Fasting glucose 4-12 mmol/l Fasting glucose > 12 mmol/l Fasting glucose > 25 mmol/l Give 200ml of 10% glucose iv over 10 min (antecubital fossa vein) Recheck blood glucose in 15 mins Ketone check required Urine ketones (Ketostix) Plasma ketones 1.5 mmol/l Urine ketones ++ Cancel Procedure Diabetes team referral Blood ketones (meter if available) Plasma ketones > 1.5 mmol/l Urine ketones > ++ Safe to Proceed with Surgery Unsafe to Proceed with Surgery Recovery: Monitor capillary glucose at least hourly CANCEL PROCEDURE Diabetes team referral Discharge: Provide information on sick day rules and written advice on monitoring their diabetes Advise ALL patients to continue their usual diabetic treatment with their evening meal. If hypoglycaemia (< 4 mmol/l) give: 200 ml of 10% glucose iv (antecubital fossa vein) Recheck glucose after 15 MINUTES If hyperglycaemia (> 12 mmol/l) and: T1D give sc rapid acting analogue based on 1 Unit of lowering blood glucose by 3 mmol/l T2D 0.1Unit/kg sc rapid acting analogue Recheck glucose after 1 HOUR Page 9 of 21
Diabetes and extended starvation (inpatient) surgery assessment and management guidelines Extended starvation means more than 12 hours without a meal missing 2 meals or more Principles 1. Not usually necessary to admit patients with diabetes the day before surgery 2. Prioritise patients with diabetes on elective surgical lists 1st on morning list 1st on afternoon list 3. Monitor capillary blood glucose hourly during surgery 4. Suggested operative glucose target range 6-10 mmol/l good 4-12 mmol/l acceptable 5. In patients on basal continue this during the operative and postoperative period Page 10 of 21
Inpatient surgery (extended starvation) non- medication guidelines Tablet Alpha glucosidase inhibitor Acarbose Meglitinide Repaglinide Netaglinide Biguanide Metformin Day before admission Day of surgery CHECK BLOOD SUGAR ON ADMISSION Morning procedure Afternoon procedure Omit MORNING dose if NBM Omit MORNING dose if NBM Give MORNING dose if eating, otherwise omit Omit LUNCHTIME dose if NBM Give MORNING dose if eating Omit LUNCHTIME dose Sulphonylurea Gliclazide Glipizide Glibenclamide Once daily Omit MORNING dose Twice daily Omit MORNING dose Once daily Omit MORNING dose Twice daily Omit MORNING dose. Give EVENING dose if eating otherwise omit Glitazone Pioglitazone DPP-IV inhibitor Sitagliptin Saxagliptin Linagliptin Vildagliptin SGLT2 inhibitor* Dapagliflozin Canagloflozin Empagliflozin Omit on day of surgery Omit on day of surgery Omit on day of surgery Omit on day of surgery GLP-1 analogue Exenatide Liraglutide Lixisenatide Omit on day of surgery Omit on day of surgery * MRHA guidance 2016: interrupt treatment with the SGLT2 inhibitor in patients who are hospitalised for major surgery or acute serious illnesses; treatment may be restarted once the patient s condition has stabilised Page 11 of 21
Inpatient surgery (extended starvation) (1) Insulin regimen Once daily evening Human NPH eg Insulatard; Humulin I Insuman Day before admission No change Day of surgery CHECK BLOOD SUGAR ON ADMISSION Morning Afternoon procedure procedure Not applicable Evening dose Usual dose if using Lantus, Levemir or Degludec with VRIII. Human analogue eg Levemir, Lantus, Degludec Once daily morning Human NPH e.g. Insulatard; Humulin I; Insuman. No change Morning dose Usual dose if using Lantus, Levemir or Degludec Omit if NPH and VRIII is use Not applicable Human analogue e.g. Levemir; Lantus, Degludec. Twice daily Human NPH e.g. Insulatard; Humulin I; Insuman. Human pre-mixed e.g. Humulin M3; Insuman Comb 25;Insuman Comb 50. No change Omit if NPH and VRIII in use Morning dose Omit Evening dose Usual dose if eating Omit if using VRIII Morning dose Halve usual dose if eating Evening dose Omit if using VRIII Human analogue premix e.g. Novomix 30; Humalog Mix 25 or Mix 50. Human analogue e.g. Levemir; Lantus. Twice daily free mix short & intermediate Short acting: e.g. animal neutral; Actrapid; Humulin S; Insuman Rapid; Novorapid; Humalog; Apidra Intermediate acting: e.g. animal NPH; Insulatard; Humulin I; Insuman Basal. No change Morning dose Omit Evening dose Usual dose if eating Omit if using VRIII Morning dose Half of total dose as INTERMEDIATE acting Evening dose Omit if using VRIII Page 12 of 21
Inpatient surgery (extended starvation) (2) Insulin regimen Three times daily premix Humulin M3, Insuman Comb 15, 25 or 50, Novomix 30, Humalog Mix 25 or Mix 50 Day before admission No change Day of surgery CHECK BLOOD SUGAR ON ADMISSION Morning procedure Afternoon procedure Morning dose Omit MORNING dose Lunchtime dose Usual LUNCHTIME dose if eating Omit if using VRIII Evening dose Usual EVENING dose if eating Omit if using VRIII Morning dose Halve usual MORNING dose Lunchtime dose Omit LUNCHTIME dose Evening dose Usual EVENING dose if eating OMIT if using VRIII Basal bolus No change Basal unchanged Basal unchanged Omit prandial while on VRIII Usual MORNING prandial if having breakfast Continuous Subcutaneous Insulin Infusion (CSII) pump No change Basal unchanged Omit bolus doses while on VRIII Omit prandial if using VRIII Basal unchanged Omit bolus doses while on VRIII Seek Diabetes Team advice Seek Diabetes Team advice VRIII = variable rate intravenous infusion Page 13 of 21
Inpatient surgery (extended starvation) variable rate intravenous infusion (VRIII) Mandatory for patients with Type 1 diabetes Strongly recommended for patients with tablet or GLP-1 injectable controlled T2D Continue basal : Humulin I, Insulatard, Insuman Basal, Lantus, Levemir, Insulin Degludec. 49.5 ml 0.9% saline plus 50 units of SOLUBLE in syringe pump Capillary blood glucose (mmol/l) Insulin infusion rate (Units per hr) < 3.9 0.5 (0.0 if basal continued) 4.0-6.9 1 7-9.9 2 10-14.9 3 15-19.9 4 > 20 5 See NUH prescription chart for further advice if required. Fluids Use 5% Dextrose with 20mmol KCl** in 500ml at 100ml/hr In patients needing fluid restrictions use 10% Dextrose with 20 mmol KCl** at 50ml/hr Administration via volumetric infusion pump. Insulin and fluids MUST be administered together via a single cannula Monitoring Hourly capillary blood glucose monitoring during VRIII Daily U+E/creatinine ** Caution in patients with Chronic Kidney Disease Page 14 of 21
Transfer from VRIII to usual Post-operative patient on VRIII NO Eating and drinking? Pre-op oral agents Pre-op (+/- oral agent(s) Pre-op GLP-1 (+/- oral agent(s) Re-start usual dose(s)/usual times May need temporary reduced dose of sulphonylurea if oral intake reduced Re-start metformin only if egfr>50 ml/min Re-start usual dose(s)/usual times May need temporary reduced dose of sulphonylurea if oral intake reduced Re-start metformin only if egfr>50 ml/min Od Bd mix Basal bolus Insulin Pump Re-start usual dose/usual time Continue VRIII until 2 hrs AFTER usual given Re-start before breakfast or before evening meal at usual dose Continue VRIII until 1 hr AFTER usual given Re-start prandial at next meal (assuming basal was continued) If basal stopped re-start at usual time and continue VRII for 2 hrs AFTER basal dose Basal rate should have been continued Usual bolus dose with next meal Seek Diabetes Team advice Page 15 of 21
Hyperglycaemia and ketone testing pre- or post-operatively In a pre or post-operative patient with hyperglycaemia (glucose >12 mmol/l) measurement of plasma ketones is recommended. Capillary glucose > 12 mmol/l Measure blood ketones using appropriate meter and test strip < 1 mmol/l 1-3 mmol/l 3-6 mmol/l > 6 mmol/l NO VRIII in progress? YES Normal Review diabetes treatment regimen T1D give sc rapid acting analogue based on 1 Unit of lowering blood glucose by 3 mmol/l T2D 0.1Unit/kg sc rapid acting analogue Recheck glucose after 1 HOUR and repeat as needed. Diabetes team review advised Check lines/infusion pump Increase infusion rate Diabetes team review advised Urgent Request for U+E, glucose, venous blood gas (ph and bicarbonate) Urgent diabetes team opinion or Diabetes Registrar (or on call medical registrar if out of hours) Page 16 of 21
Patient information leaflet for patients undergoing surgery or procedures requiring a period of starvation Treatment with tablets or injections of, Exenatide or Liraglutide Please follow the instructions in the enclosed table which provide information on what you should do with your tablet or injection treatment prior to your planned surgery If your operation is in the morning Do not eat any food after midnight Drink clear fluids such as water, black tea of coffee or sugar-free squash if required up until 05.00am If your operation is in the afternoon Eat breakfast before 06.00am and take no food after this time Drink clear fluids such as water, black tea of coffee or sugar-free squash if required up until 10.00am When you travel to and from the hospital for your operation please carry some glucose tablets, or a sugary drink (such as a 200ml carton of orange juice) with you What if I have a hypo? If you have symptoms of a low blood sugar such as sweating, shaking, dizziness, poor concentration or blurred vision please test your blood sugar if able to do so. If it is less than 4 mmol/l take 4 glucose tablets or a 200ml carton of orange juice, or ½ can of a sugary drink such as coca cola. Re-check your blood sugar 10-15 mins after treating the hypo. Inform the staff at the hospital if you have had to do this. Remember to bring with you to the hospital Glucose tablets, a carton of orange juice or a sugary drink Your blood glucose monitoring equipment if you usually monitor your sugars at home) The tablets or injections you usually take for your diabetes After your operation You will be offered food and drink when you feel able to eat. You should resume your usual treatments for diabetes once you are eating and drinking Be aware that your sugar levels may be higher than usual for the first day or two after surgery If you feel unwell after returning home please refer to the SICK DAY RULES information sheet Contact your GP or diabetes care provider if things don t improve. Page 17 of 21
Sick Day Rules for People with Diabetes What to do if you are unwell NEVER stop taking your or tablet illness usually increases your body s need for TEST your blood sugars every 2 hours, day and night TEST your urine for KETONES every time you go to the toilet or test your blood ketones every 2 hours if you have a suitable meter DRINK at least a cup (100 ml) of water/sugar free fluid every hour aim to drink about 5 pints (2.5 litres) per 24 hours REST and avoid strenuous exercise since this may increase your blood sugars during exercise EAT normally if you can. If you have a smaller appetite than usual replace a meal with: 400ml milk or 200ml carton fruit juice or 200 ml non-diet fizzy drink or 1 scoop ice cream When should I call for help? CONTINUOUS diarrhoea and/or vomiting and/or a high fever UNABLE to keep food down for 4 hours or more HIGH blood glucose levels (over 12 mmol/l) with symptoms of illness you may need more KETONES at 2++ or 3++ in your urine or more than 1.5 mmol/l in your blood you may need more If you are concerned please CONTACT the person or the clinical service that normally helps you to look after your diabetes OUTSIDE NORMAL WORKING HOURS Consult the local out of hours service or go to your local hospital Emergency Department Page 18 of 21
Patient Discharge Letter Advice for patients with diabetes who are discharged following a surgical procedure 1. Continue to take your or tablet medication as usual when you get home. 2. Check your blood sugars if you have the equipment to do so 4 times per day, or more frequently if you don t feel well, or are feeling or being sick. 3. Your blood sugar may be higher than usual; this is not a concern provided you are feeling well. 4. If you are feeling unwell, especially if you are being sick and unable to take food or medication please see the accompanying Sick Day Rules information sheet for further advice. Page 19 of 21
Primary care input to service Surgical referral diabetes data factsheet NHS Diabetes has recently produced recommendations on the management of diabetes in patients undergoing surgery The recommendations emphasise the importance of optimising diabetes management prior to surgery, promoting day surgery where possible, avoiding the use of unnecessary infusions and promoting an early resumption of a patient s usual diet and diabetes management. Please include the following information in ANY referral of a patient with diabetes for possible surgery: Up to date current diabetes care Duration and Type of diabetes Main site of delivery of care Primary or Secondary care Co-morbidities Treatment o For diabetes oral agents/non- injectables/ regimen o For other co-morbidities Specific complications of diabetes At risk foot Renal impairment Cardiac disease Hypertension Most recent values for BMI BP HBA1c egfr Page 20 of 21
Pre-operative Assessment (Diabetes) Please circle or add data as appropriate Diabetes type Type 1 Type 2 Other: Details Diabetes duration Usual place of care... yrs Primary care GP Secondary care Consultant Treatment oral agent (name) Metformin SU Pioglitazone Gliptin SGLT2 Acarbose Dose and frequency Treatment - injection GLP-1 name Insulin name Dose/frequency Complications (details if available) (free text) At risk foot Renal impairment Cardiac disease Latest data BMI. Kg/m 2 Date././. BP../.. mmhg Date././. Latest lab data egfr ml/mim Date././. HBA1c mmol/mol Date././. Page 21 of 21