Detection and management of perioperative blood glucose abnormalities?

Yi Rong,Wei-Bing Shung

aDepartment of First Clinical Medical College, Shanxi Medical University, Taiyuan, Shanxi 030001, China

bDepartment of Urology, The First Hospital of Shanxi Medical University, Taiyuan, Shanxi 030001, China

Abstract: Diabetes mellitus is a common chronic disease.With the improvement of living standards,the prevalence of diabetes mellitus in China is increasing.There are now more people with diabetes in China (>100 million) than in any other country.About half of these people with diabetes need to undergo at least one procedure in their lifetime.Diabetic patients have a much higher probability of perioperative dysglycemia than the normal population,which has a great impact on their prognosis.In addition,non-diabetic patients may also have abnormal blood glucose levels due to various reasons during the perioperative period,which will also lead to a series of adverse consequences.This article reviews the perioperative blood glucose management of patients to provide a reference for improving their health status.

Keywords: blood glucose monitoring ?diabetes ? dysglycemia ? perioperative ? postoperative rehabilitation ? review

1.Introduction

Less than 500 million people worldwide have diabetes,and this number is expected to increase by 25% and 51% in 2030 and 2045,respectively.1Diabetes mellitus is an important cause of perioperative dysglycemia.In addition,factors such as surgical stimulation,use of anesthetic drugs,patient tension,and perioperative fluid management may also lead to perioperative dysglycemia in non-diabetic patients.It has been shown that approximately 60% of patients undergoing cardiac surgery experience stress hyperglycemia.2Perioperative dysglycemia not only increases the mortality of surgical patients but also increases the incidence of complications such as infection,wound non-union,renal impairment,and cardiovascular and cerebrovascular events,prolongs the length of hospital stay of patients,and affects the long-term prognosis.In China,more patients require perioperative glucose management than in any other country;however,there are no high-quality evidence-based glucose management guidelines.3At the same time,in the process of perioperative blood glucose monitoring and management,it may face complex situation.It is necessary to detect a variety of indicators and adopt a variety of different management strategies to different conditions,such as adjusting the use of hypoglycemic drugs,supplementing insulin to treat hyperglycemia,carrying out nutritional management,and treating possible hypoglycemia.However,other reviews in this field focus on describing one or a few management strategies,and there is no article describing multiple management strategies at the same time.Therefore,this article reviews the 2 aspects of blood glucose monitoring and management,focusing on a variety of management methods including the adjustment of oral drugs,insulin treatment strategies for perioperative hyperglycemia,nutritional management,prevention of complications,prevention of stress hyperglycemia,and treatment strategies for hypoglycemia.

2.Classification and mechanism of perioperative dysglycemia

Common perioperative glucose abnormalities include hyperglycemia,hypoglycemia,and glucose fluctuations.

2.1.Hyperglycemia

Perioperative hyperglycemia usually predicts postoperative complications and high mortality and can be divided into 2 categories: one is elevated blood glucose with diabetes,and the other is surgery-related stress hyperglycemia;the former is more common,and the latter is characterized by transient and recoverable hyperglycemia.Perioperative hyperglycemia is caused by 2 factors: on the one hand,the susceptibility of patients to their own diseases;that is,diabetic patients have an increased risk of hyperglycemia because they have absolute or relative insulin secretion deficiency or insulin resistance caused by body endocrine dysfunction;on the other hand,it is non-diabetic patients’ own disease factors,including inadequate preoperative preparation,surgical operation,and anesthesia-related stimulation.Preoperative mental anxiety and surgical and anesthetic stimulation can also cause increased secretion of insulin antagonistic hormones such as glucocorticoids,glucagon,and catecholamines in patients,resulting in increased blood glucose.The risk of postoperative complications in general surgical patients is related to the severity of hyperglycemia,and patients without a history of diabetes (stress hyperglycemia) have a higher risk of death compared to patients with a known diagnosis of diabetes.3

2.2.Hypoglycemia

Hypoglycemia is a condition that is easily ignored but very dangerous during the perioperative period and can lead to shock,coma,brain damage,induced epilepsy,arrhythmia,and even cardiac arrest in patients.The main causes of hypoglycemia are insufficient glucose supplementation after perioperative fasting,improper use of preoperative insulin and oral hypoglycemic agents in diabetic patients,and excessive or inappropriate intraoperative insulin infusion.Perioperative hypoglycemia is more common in diabetic patients than in non-diabetic patients.Surveys have shown that the incidence of hypoglycemia in hospitalized diabetic patients is about 14%,and special attention should be paid to prevent it.

2.3.Blood glucose fluctuation

Improper glycemic control in perioperative patients can cause glycemic excursions.Blood glucose fluctuation is more harmful to patients than persistent hyperglycemia.4Perioperative glucose fluctuations are inextricably associated with postoperative outcome,complications,and mortality.5

3.Perioperative related monitoring

3.1.Perioperative blood glucose monitoring

Perioperative blood glucose testing should run through the whole process before,during,and after surgery.The Chinese Expert Consensus on Perioperative Blood Glucose Management 2020 states that perioperative blood glucose should be controlled between 7.8 mmol/L and 10 mmol/L.Glycemic control goals also differ for different types of surgery.For patients undergoing cardiac surgery,the intraoperative blood glucose control target is 8.3–11.1 mmol/L,and the postoperative blood glucose control target is <12.0 mmol/L;for patients undergoing neurosurgery,the intraoperative blood glucose control target is 5.0–10.0 mmol/L,and the postoperative blood glucose control target is <12.0 mmol/L;for patients undergoing fine surgery,the preoperative blood glucose control target is 5.0–7.2 mmol/L,while for patients with long duration of diabetes and difficulty in achieving the above blood glucose criteria,the blood glucose increases to <8.3 mmol/L,the intraoperative blood glucose is controlled at 6.7–11.1 mmol/L,and the postoperative blood glucose is controlled below 12.0 mmol/L.3For patients with severe comorbidities or high risk of hypoglycemia,the glycemic control target can be relaxed to 10.0–13.9 mmol/L.4Studies6have shown that 30%–80% of patients treated in the intensive care unit (ICU) during the perioperative period experience hyperglycemia.This stress hyperglycemia is induced by iatrogenic stimulation and inflammation and requires aggressive treatment.A meta-analysis6showed that 7.8–10 mmol/L (141–180 mg/dL) was the optimal glycemic control range to reduce ICU mortality and avoid hypoglycemia.

3.1.1. Preoperative blood glucose monitoring

Preoperative doctors should routinely test the patients’fasting blood glucose.For patients with fasting blood glucose in the range of 6.1–7.8 mmol/L and risk of diabetes,it is recommended to perform glucose tolerance test (OGTT) to diagnose whether they have diabetes.It is best to combine glycosylated hemoglobin (HbA1c) test to distinguish whether the cause of abnormal blood glucose is elevated blood glucose with diabetes or surgery-related temporary stress hyperglycemia.In addition to measuring fasting blood glucose in the morning,a total of 7 blood glucose measurements before and after meals and at bedtime are generally required.For patients who have been diagnosed with diabetes,physicians should comprehensively evaluate the patients’ preoperative blood glucose levels and diabetes-related complications that may affect the prognosis of surgery so as to determine whether the patient can undergo surgery and select the appropriate timing of surgery.The operation time should be determined by the doctor in charge,anesthesiologist,endocrinologist,and nurse through consultation.For patients with frequent hypoglycemia and blood glucose fluctuations,the doctor in charge should proactively invite an endocrinologist for consultation and develop a blood glucose management strategy most favorable to the patients.

3.1.2. Intraoperative blood glucose monitoring

Blood glucose should be monitored at least once during and for a short period of time after surgery.Reducing or suspending intravenous insulin when blood glucose levels reach 8 mmol/L (144 mg/dL) has proven beneficial in practice.When blood glucose is in the range of 6.1–8 mmol/L (110–144 mg/dL),intensive monitoring is required,and if blood glucose is <6.1 mmol/L(110 mg/dL),glucose should be considered and nutritional therapy should be started or restarted.6Minor surgery (<1 h) usually does not require regular use of insulin if patients maintain good glycemic control with diet,exercise,or oral hypoglycemic agents.7Insulin can be injected subcutaneously for small surgeries if high blood glucose is found;blood glucose should be closely monitored during surgery,and the speed of the insulin intravenous infusion pump should be dynamically adjusted according to blood glucose results.8Continuous intravenous insulin infusion should be selected during large and medium-sized surgeries.

3.1.3. Postoperative blood glucose monitoring

At the end of the operation,blood glucose monitoring should be started immediately and performed 4–8 times a day.The main monitoring time points are fasting in the morning,before and after meals,bedtime and at night.And before discharge,patients were given relevant health education on how to monitor blood glucose,how to take oral hypoglycemic agents and inject insulin,and when to return for follow-up.3This ensures that patients can manage their blood glucose correctly after discharge.

For patients requiring intravenous insulin injection,critically ill patients,and patients undergoing major surgery,blood glucose should be monitored every 1–2 h.For patients in postoperative intensive care or mechanical ventilation and patients without cardiovascular disease or hepatic or renal dysfunction,target glucose levels are 7.8–10.0 mmol/L;for patients with cardiovascular or cerebrovascular disease or hepatic or renal dysfunction,target glucose control is 8.0–12.0 mmol/L,but clinically,the upper limit of target glucose control can be increased to 13.9 mmol/L and blood glucose levels are monitored every 1–4 h.3

Corticosteroids may cause hyperglycemia in patients and should be used with caution following surgery.Cortisol binding globulin (CBG) should be measured hourly for at least 4 h after dosing if corticosteroids are necessary.7In addition,postoperative use of non-steroidal drugs may also lead to hypoglycemia and should be prevented.

3.2.HbA1c monitoring

HbA1c is an important preoperative test that can be used to distinguish diabetic hyperglycemia from stress hyperglycemia,thereby identifying the etiology of hyperglycemia in patients.In addition,the HbA1c test has the advantages of simplicity,stable results,small variability,and freedom from eating time and short-term lifestyle changes.Now,HbA1c ≥6.5% has been used as one of the bases for the diagnosis of diabetes.4It has been shown that only Fasting Blood Glucose (FBG) is detected,and 2-thirds of hyperglycemic patients will be missed.In Abdelmalak’s study,surgical patients who had preoperative hyperglycemia but were not diagnosed with diabetes had a higher mortality rate 1 year after surgery;therefore,these investigators recommended routine preoperative HbA1c testing for suspected diabetic patients to improve care.9In addition,in clinical practice,patients with high risk factors for diabetes such as Body Mass Index (BMI) >25,age >45 years,and family history of diabetes are generally screened for HbA1c.Some studies have also shown that elevated HbA1c in diabetic patients is associated with increased risk of adverse outcomes such as high morbidity,mortality,myocardial infarction,and early postoperative infection.It has been shown that patients undergoing bilateral internal thoracic artery (BITA) transplantation during coronary artery bypass grafting (CABG) have a 31%increased risk of postoperative infection for each unit increase in HbA1c.10

4.Perioperative management

4.1.Adjustment of preoperative hypoglycemic regimen

For patients with diabetes,oral antidiabetic drugs are often required in patients with type 2 diabetes in addition to diet and exercise to control blood glucose;if oral antidiabetic drugs still fail to achieve adequate glucose control,insulin can be added to the treatment regimen of oral drugs.11For those patients with type 1 diabetes who lack insulin secretion,it must be artificially replaced by soluble biosynthetic human insulin products.At present,the common hypoglycemic drugs used to treat diabetes can be divided into 7 categories according to their mechanism of action,which are insulin secretagogues,biguanides,a-glucosidase inhibitors,thiazolidinediones,dipeptidyl peptidase-46,Glucagon-like Peptide-1 (GLP-1)receptor agonists,insulin and their analogues.

Metformin,as a first-line agent for Type 2 Diabetes Mellitus (T2DM),needs to be discontinued preoperatively in the face of patients with moderately diminished renal function and 48 h preoperatively in patients requiring general anesthesia surgery.However,it need not be discontinued in patients undergoing minor surgery without bed rest and without severe renal failure.Insulin secretagogues are divided into sulfonylureas and non-sulfonylureas,the most commonly used of which are glinides.At present,it is controversial whether sulfonylureas and glinides should be discontinued prematurely before surgery.These 2 drugs have the effect of promoting insulin secretion.Therefore,in order to avoid hypoglycemia in patients who fast for a long time before surgery,sulfonylureas and glinides should be discontinued 1 d before surgery in clinical practice.GLP-1 receptor agonists are generally discontinued before surgery due to the greater side effects of gastrointestinal reactions.Sodium glucose cotransporter 2 inhibitors (SGLT2i),such as dapagliflozin,have begun to be widely used clinically as novel agents.The American Endocrine Society and the American Association of Clinical Endocrinologists recommend stopping SGLT2i 24 h before surgery.12The 2020 edition of the Expert Consensus on Perioperative Blood Glucose Management even more controls the duration of use to 48 h before surgery.

For patients with type 2 diabetes requiring insulin therapy,insulin use should be continued before surgery,and for patients with type 1 diabetes requiring surgery,insulin should be continued during the perioperative period.Surgical stress can lead to severe hyperglycemia or ketoacidosis.These patients should receive 80% of their basal insulin dose in the evening before surgery and in the morning after surgery to prevent dysglycemia.13For patients dosed twice daily,reduce insulin injection by 0–50% 2 d before surgery for patients requiring insulin therapy.14Whereas intermediate-acting(NPH) insulin and premixed formulations should be decreased by 20% the night before surgery and by 50%the morning of surgery.In addition,we recommend that patients with type 2 diabetes maintain their dose of NPH or premixed insulin on the morning of surgery.

4.2.Perioperative hyperglycemic insulin treatment strategies

At this stage,there is no strict regulation on whether surgery should be delayed in patients with poor blood glucose management.When HbA1c or fasting glucose values exceed a certain range,an appropriate strategy to delay surgery for patients tends to be beneficial for patients.Consensus recommendations issued in the 2011 National Health Service (NHS) diabetes guidelines recommend that elective surgery should be delayed until HbA1c levels improve if mean HbA1c levels are ≥8.5%in the first trimester.7Emergency surgery should also be avoided as much as possible when patients have high blood glucose,and the 2020 edition of the Expert Consensus on Perioperative Blood Glucose Management states that when fasting or random blood glucose is≥13.889 mmol/L,surgery should be decided after comprehensive evaluation by multidisciplinary physicians.When planning the operating room list,it is preferable to schedule the diabetic patients at the earliest available time to reduce their fasting time.11

Patients whose HbA1c is controlled below 7% by diet,oral medication,or non-insulin therapy do not require insulin for ambulatory minor surgery.15For patients with possible perioperative hyperglycemia,whether combined with diabetes or stress-induced hyperglycemia,fasting blood glucose before 3 meals,2 h after 3 meals,and bedtime blood glucose should be measured during the perioperative period before surgery.Blood glucose should be measured every 4–6 h in patients under fasting.When blood glucose values are >10.0 mmol/L,numerous expert consensuses recommend intravenous insulin,and for fasting patients,hypoglycemic therapy is required when blood glucose is >7.8 mmol/L.16

There are 3 types of insulin therapy: basal insulin therapy,intensive insulin therapy,and variable rate intravenous insulin infusion.

(1) Basal insulin treatment strategies include a single injection of basal insulin and basal insulin combined with preprandial insulin subcutaneous injection,and basal insulin therapy can be used as the best regimen for perioperative glycemic control.17

(2) Perioperative intensive insulin therapy: the purpose of intensive insulin therapy is to accurately control the range of perioperative blood glucose fluctuations in patients.However,strict control of the patients’ blood glucose range is not recommended now,and mild hyperglycemia may be beneficial to the patients.At present,perioperative intensive insulin therapy has no obvious advantage over basal insulin,but may increase the risk of hypoglycemia.In addition,the American College of Physicians explicitly prohibits the use of intensive insulin therapy in surgical intensive care and recommends that blood glucose be controlled at 7.8–11.1 mmol/L.18

(3) The indications for variable rate intravenous insulin infusion therapy include: (1) patients with longer operation time;(2) patients with type 1 diabetes who did not receive insulin background infusion;(3) patients with poor blood glucose control,i.e.,Hb1Ac >6.9 mmol/mol;(4) patients with emergency diabetes;(5) patients with severe disease(such as sepsis,etc.) who could not control blood glucose well;and (6) patients who could not implement other hypoglycemic measures.19In addition,for patients who have been fasted for a long time or operated for >3 h before surgery,a regimen of glucose,insulin combined with potassium chloride combined with co-infusion can be used in combination with 10% glucose solution,500 mL+15 U insulin+10 mmol/L potassium.

Common methods of insulin injection are subcutaneous and intravenous.Patients undergoing ambulatory or short-term surgery (operating room time <4 h)usually choose subcutaneous insulin therapy,which is performed within 4 h,limiting the number of intraoperative subcutaneous insulin injections to 2 and potentially reducing the risk of hypoglycemia.19Intravenous insulin infusion is often preferred for patients with operating time >4 h,large hemodynamic changes during the procedure,and critically ill conditions.Insulin pumps are now more commonly used for hypoglycemic therapy in T1DM or T2DM that is not adequately controlled with other non-insulin therapies.However,to date,there is no public consensus or guideline on perioperative insulin pump use in diabetic patients requiring surgical procedures.20The insulin pump cannot control the patients’blood glucose well in the face of major hemodynamic changes.Therefore,for patients who require longer surgery,have a large amount of fluid loss during surgery,and require emergency surgery,consideration should be given to withdrawing the insulin pump and changing to intravenous insulin to better control blood glucose.In addition,there is insufficient evidence to demonstrate the safety and effectiveness of continuous subcutaneous insulin pumps during the perioperative period,and the disadvantages of insulin pumps include abnormal power supply,insulin insufficiency,infusion system blockage,and insulin leakage,which may lead to treatment interruption and severe intraoperative hyperglycemia,hypoglycemia,or ketoacidosis.3

4.3.Nutritional management

Nutritional assessment of patients admitted to the hospital is an important part of preoperative assessment.Because diabetic patients themselves have endocrine dysfunction,in the process of perioperative nutritional support,malnutrition or overnutrition is more likely to occur,increasing the risk of various complications and affecting the prognosis of patients.According to the results of nutritional assessment,doctors can help to develop a reasonable preoperative nutritional support program for patients.Professional nutritional support should be considered for any patient who is unable to ingest adequate nutrition and remains in the ICU for >5 d or in the general ward for 7–14 d.21Common approaches to nutritional support include enteral nutritional support and parenteral nutritional support.Enteral and parenteral nutrition has been shown to be effective in preventing hunger and malnutrition in hospitalized patients.22In clinical practice,enteral nutrition is superior to parenteral nutrition.21The relationship between the development of hyperglycemia during total parenteral nutrition (TPN) and poor clinical hospital outcomes is well documented.23Enteral formulas containing lower carbohydrate may reduce the risk of perioperative hyperglycemia and insulin injection compared with standard formulas in patients with diabetes,and long-acting insulin is often required to control blood glucose in patients indicated by enteral nutrition.In patients on parenteral nutrition,glucose administration rates above 4 mg/kg/min increase the risk of hyperglycemia in non-diabetic critically ill patients.In the meantime,it has been shown that insufficient glucose infusion increases mortality in ICU patients.24It is suggested that daily glucose infusion should be strictly controlled in patients with parenteral nutrition support,which should not only meet the energy requirements of the body,but also prevent the occurrence of hyperglycemia.

Diabetic patients should avoid prolonged fasting.Low carbohydrate diets contribute to increased insulin secretion and improve glycemic control.22In addition,in order to reduce the fasting time of patients,in clinical practice,diabetic patients are often scheduled for surgery in the morning,which can reduce the risk of abnormal blood glucose levels due to changes in the original drug and dietary regimen.

4.4.Management of complications

If the patient is diagnosed with diabetes by blood glucose and HbA1c tests,clinicians should pay special attention to the presence or absence of complications of diabetes,and for patients with complications,the severity of complications should be assessed preoperatively to determine whether the patient can undergo surgery.Gastroparesis refers to delayed gastric emptying in the absence of mechanical infarction,typically manifested as nausea,vomiting,abdominal distension,anorexia,etc.,and often occurs in patients with type 1 or type 2 diabetes.Gastroparesis should be assessed before anesthesia is administered by the anesthesiologist as it poses a risk of reflux aspiration upon induction of anesthesia.Diabetic patients are often associated with cardiovascular system-related complications.Silent myocardial ischemia is present in 30%–50% of asymptomatic T2D patients without a history of cardiac disease but with cardiovascular risk factors.23It often indicates a poor prognosis.Diabetic cardiomyopathy is the leading cause of heart failure in diabetic patients.Cardiac autonomic neuropathy(CAN) increases the risk of cardiovascular events and sudden death and should also be examined.Therefore,for diabetic patients,Electrocardiogram (ECG),myocardial injury markers,treadmill provocation test and various imaging examinations should be routinely performed before surgery to assess the cardiovascular status of patients.Chronic diabetic nephropathy(DN) increases the risk of perioperative acute renal failure,and clinicians should measure glomerular filtration rate preoperatively to assess renal function,determine whether surgery can be performed,and perform further targeted treatment under the guidance of an endocrinologist.

In addition to the above complications,perioperative hyperglycemia may lead to acute complications in patients,including diabetic ketoacidosis and hyperosmolar hyperglycemia syndrome.Diabetic ketoacidosis is common in patients with T1DM,as T1DM patients often have a tendency to spontaneously develop Diabetic Ketoacidosis (DKA),and T2DM can also occur in rare cases.When the blood glucose level of diabetic patients receiving insulin therapy is ≥13.9 mmol/L,clinicians should further monitor blood gas analysis and blood/urine ketone body to determine whether the patient has diabetic ketoacidosis.If the patient is diagnosed with diabetic ketoacidosis,fluid replacement should be performed immediately combined with ultra-short-acting insulin to reduce the blood glucose below 11.1 mmol/L,but attention should be paid to alkali supplement.Compared with ketoacidosis,hyperosmolar hyperglycemia syndrome is more common in patients with T2DM.Hyperosmolar hyperglycemia syndrome is mainly characterized by severe hyperglycemia,hyperosmolality and dehydration,manifested as severe dehydration,confusion,and coma.For patients suspected of hyperosmolar hyperglycemia syndrome,plasma osmolality should be measured in time to confirm the diagnosis.Once determined,fluid replacement and insulin infusion should be performed immediately to reduce blood glucose to <16.7 mmol/L.

4.5.Prevention of stress hyperglycemia

The stimulation of surgery and anesthesia promotes the release of anti-insulin hormones such as catecholamines and glucocorticoids and then makes the body appear insulin resistant,ultimately leading to hyperglycemia in patients.This state of insulin resistance is most pronounced on the first day after surgery and may persist for 9–21 d after surgery.25Enhanced postoperative recovery (ERA) programs advocate consumption of carbohydrate-rich beverages within 2 h before surgery,which avoids catabolic states associated with hunger and has been shown to improve insulin sensitivity.26The degree of insulin resistance is related to the surgical situation and the type of anesthesia,for example,thoracoabdominal surgery has a higher risk of stress hyperglycemia than peripheral surgery,while laparoscopic surgery has a lower risk of stress hyperglycemia than open surgery.25The type of anesthesia also impacts the hyperglycemic response during surgery.Compared with local or epidural anesthesia,general anesthesia is more frequently associated with hyperglycemia and increased levels of catecholamines,cortisol,and glucagon.27Therefore,special attention should be paid to blood glucose monitoring during surgical or anesthetic procedures with a high risk of stress hyperglycemia,and hypoglycemic treatment should be performed in time after the occurrence of dysglycemia.

4.6.Treatment of hypoglycemia

Blood glucose <3.9 mmol/L can be diagnosed as hypoglycemia.Compared with hyperglycemia,hypoglycemia is more likely to be ignored during surgery;therefore,special attention should be paid to palpitations,hyperhidrosis,mental changes and other symptoms that may indicate hypoglycemia in patients during the perioperative period.In clinical practice,any unexplained discomfort should be treated as hypoglycemia,even if the patients’ blood glucose is within normal limits.Some patients may experience frequent hypoglycemia during blood glucose monitoring,which is not uncommon in 40% of patients with type 1 diabetes and 10% of patients with type 2 diabetes requiring insulin to control blood glucose,and is also occasionally observed in patients with type 2 diabetes who take oral drugs to control blood glucose.28In the fasted state,when blood glucose falls below 4.4 mmol/L,10 g of high glucose is recommended intravenously and blood glucose is monitored every 15–30 min.When blood glucose levels are between 4.4 mmol/L and 5.6 mmol/L,an intravenous infusion of 5% glucose at 40 mL/h or 10% glucose at 20 mL/h is recommended,and blood glucose monitoring is performed every 1 h;if hypoglycemia occurs in the non-fasted state,patients are advised to take 10–25 g of glucose orally to rapidly absorb carbohydrates (e.g.,glucose-based beverages);for patients unable to ingest oral glucose,20–50 mL of 50% glucose intravenously,followed by continuous intravenous infusion of 5% or 10% glucose to maintain blood glucose levels.Monitor blood glucose levels every 15 min until ≥5.6 mmol/L.3

5.Summary

Blood glucose monitoring and management are important for patients undergoing surgical treatment.Perioperative dysglycemia increases not only the mortality of surgical patients but also the incidence of complications,such as infection,wound non-union,renal impairment,and cardiovascular and cerebrovascular events,affecting the health of patients.Clinicians should individualize the management of patients at different stages according to the severity of the patients’ conditions,relevant examination indicators,length of operation,location and other factors,and the management plan should be jointly developed by the physician in charge,anesthesiologist,endocrinologist,and nurse to prevent abnormal blood glucose levels and related complications.For patients who have already developed abnormal blood glucose levels or positive complications,scientific measures should be actively taken to control blood glucose and prevent further serious consequences.

Ethical approval

Ethical issues are not involved in this paper.

Conflicts of interest

All contributing authors declare no conflicts of interest.