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Page 10 of 13 Fearon et al. Metab Target Organ Damage 2022;2:13 https://dx.doi.org/10.20517/mtod.2022.12

cardiac and non-cardiac surgery and can reduce the amount of insulin required on the day of surgery [50-52] .
In contrast, guidelines around the use of sodium-glucose co-transporter 2 (SGLT2) inhibitors are clear that
these medications should be stopped three days before surgery and should not be used in critical illness,
[53]
prolonged fasting status, ketonuria, or ketonemia .

In general, pre-operative hyperglycaemia does not require surgery cancellation except in diabetic
ketoacidosis or hyperosmolar nonketotic states, which may be confirmed with further biochemistry testing
and require specific management. However, the person should be started on an insulin infusion with
additional monitoring of blood glucose levels and could proceed to surgery if levels were below 16.6
mmol/mol .
[54]

Insulin use perioperatively is clearly outlined in CPOC guidelines, and up-to-date information can be found
[55]
in the perioperative handbook provided by the Clinical Pharmacy Association . In randomised studies,
insulin delivery intraoperatively is of predominant interest, with options such as fully closed-loop insulin
delivery showing promising outcomes for people with T2DM. Studies have shown that response to intra-
operative delivery of insulin cannot be predicted based on diabetic status or previous use of insulin and does
not appear to correlate with the presence of obesity or metabolic syndrome . Duggan and Chen provide a
[56]
comprehensive review of intra-operative glycaemic control. Epidural anaesthesia is associated with reduced
intra-operative blood glucose levels, and different types of general anaesthesia, particularly total intravenous
anaesthesia, are associated with better glycaemic control intra-operatively .
[54]

CONCLUSION
Improving perioperative glycaemic control starts with identifying, screening, and standardising criteria for
safe elective surgery. Strategies for improving preoperative glycaemia and insulin resistance include calorie
restriction, newer oral and injectable medications, and bariatric-metabolic surgery interventions such as
intragastric balloons. The best strategy for each person should be based on other medical complications,
their circumstances and wishes, and the availability of local resources and treatments. Further research
could focus on the impact of these interventions on important clinical outcomes such as re-operation rates
and mortality.

DECLARATIONS
Author’s contributions
Contribution to the writing and editing of the manuscript: Fearon NM, Pournaras DJ

Availability of data and materials
Not applicable.

Financial support and sponsorship
None.

Conflicts of interest
Pournaras DJ has received consulting fees from Johnson and Johnson, in addition to payments for lecturing
and education events from Johnson and Johnson, Medtronic and Novo Nordisk.

Ethical approval and consent to participate
Not applicable.