Management of Adults with Diabetes undergoing Surgery and Elective Procedures UHL Guideline – April 2013 The aim of the guideline is to improve standards of care for people with diabetes undergoing operative or investigative procedures requiring a period of starvation These guidelines cover all stages of the patient pathway from primary care referral to surgical outpatients, pre-operative assessment, hospital admission, surgery, post-operative care and discharge The guidelines are 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

Recommendations for each stage of the patient pathway are intended to stand alone so that individual health care professionals can identify their role in the process Quick reference contents page List of appendices Both of the above at beginning of document to assist finding the relevant section

Core principles Patient should be involved in care planning Where possible diabetes management should be optimised prior to surgery (HbA1c <9.0% or 75mmol/mol) Diabetes management plan should be made when patient attends pre-assessment clinic Where possible patients should be admitted on the day of surgery with advice regarding management of their usual diabetes medication Starvation time should be minimised Patients should resume eating and drinking, usual medication and self-management as soon as possible

Referral criteria and contact numbers for the diabetes team given Patients missing only one meal - aim to avoid use of iv insulin infusion – diabetes should be managed with modification of usual treatment where possible. Where iv insulin infusion required (eg, >1 missed meal, poor diabetes control, emergency admission) ensure iv substrate fluid is prescribed with iv insulin infusion Monitor CBG hourly during peri-operative period Target blood glucose should be 6-10mmol/l (4-12mmol/l acceptable) – if not achieving then review medication, make necessary alterations and consider referral to specialist DSN team. Clear guidance is given regarding management of hyperglycaemia during peri-operative period Hypoglycaemia should be managed according to UHL guidance.

Staff responsibilities All staff are recommended to undertake the national e-learning modules – Safe Use of Insulin and Intravenous Insulin Infusions – These slides are for use only as an introduction to the full guideline. Staff should ensure they have read the full document and familiarised themselves with the sections that relate to the stage of the pathway for which they are responsible. The following 2 slides summarise the referral pathway for patients and also a flow chart to assist when determining treatment pathways. Teams should ensure that any patient information leaftlets updated where necessary. It is important to appreciate that this is a guideline and there will be patients for which strict adherence to the guideline is felt to be inappropriate. The teams involved should discuss and document these decisions.

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