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Preoperative Insulin Intensification to Improve Day of Surgery Blood Glucose Control

Background: Guidelines offer varying recommendations for preoperative long-acting basal insulin dosing, despite mounting evidence of the advantages of maintaining perioperative glucose levels between 80 and 180 mg/dL. Observations: We iteratively adjusted health care practi- tioner (HCP) instructions to intensify insulin dosing on the evening before surgery for 195 consecutive patients with di- abetes mellitus treated with long-acting basal insulin with an evening dosage. Baseline data was collected in phase 1. In phase 2, the preoperative insulin dose on the evening before surgery was increased for patients with hemoglobin A 1c (HbA 1c ) > 8%; in phase 3, it was increased for patients with HbA 1c ≤ 8% while sustaining the phase 2 change. Increased preoperative insulin doses did not change the rates of day of surgery (DOS) hyperglycemia or hypoglycemia. Overall, HCP adherence to the modified protocols was high (89%). A de-cline in HCP adherence after phase 2 protocol change was associated with a transient increase in DOS hyperglycemia. Patient adherence to preoperative medication instructions was high (86%) and was not affected by protocol changes. Conclusions: Preoperative insulin intensification the evening before surgery did not change rates of DOS hyperglycemia or hypoglycemia. HCP adherence decreased transiently, which briefly increased DOS hyperglycemia rates in some patients.