es-preop-bg-only-target

name	es-preop-bg-only-target
description	If achieving preoperative HbA1c <8% is not feasible, target preoperative blood glucose concentrations of 100 to 180 mg/dL instead. Trigger phrase: "Cannot meet HbA1c goal, what glucose target should we use preoperatively?"

Target preoperative blood glucose 100-180 mg/dL when HbA1c target not feasible

STEP 1 — Gather Information

Collect the patient's most recent HbA1c, assess feasibility of achieving <8% preoperatively (consider time until surgery, resources, and patient factors), and obtain a current point-of-care blood glucose (POC-BG) measurement.

STEP 2 — Rule In / Rule Out

Is achieving preoperative HbA1c <8% feasible? If yes, target HbA1c <8% and BG 100–180 mg/dL per Recommendation 5.1. If not feasible, proceed to Step 3.

STEP 3 — Classify or Stratify

Classify the preoperative POC-BG: if 100–180 mg/dL, continue current regimen; if <100 mg/dL, evaluate for hypoglycemia risk; if >180 mg/dL, initiate corrective insulin to bring glucose into target range.

STEP 4 — Decide

Adjust diabetes management (e.g., insulin dosing, noninsulin agents) to maintain preoperative BG within 100–180 mg/dL, rechecking POC-BG 1–4 hours before surgery; if persistently outside range, consider adding scheduled insulin therapy.

Clinical Guardrails / Mimics / Pitfalls

Do not rely solely on HbA1c when conditions affecting its accuracy are present (anemia, hemoglobinopathies, chronic renal failure, alcoholism, drugs, large BG variations); avoid preoperative caloric carbohydrate-containing oral fluids; do not use sliding scale insulin alone for persistent hyperglycemia ≥180 mg/dL; ensure BG measured 1–4 hours preoperatively.

Concrete Clinical Example

A patient with type 2 diabetes scheduled for elective hip replacement in 2 days has HbA1c 8.5% and cannot realistically achieve <8% preoperatively. POC-BG measured 2 hours before surgery is 165 mg/dL (within target); proceed with surgery. If POC-BG were 210 mg/dL, administer 4 units rapid-acting insulin and recheck in 1 hour.

Source: Management of Hyperglycemia in Hospitalized Adult Patients in Non-Critical Care Settings: An Endocrine Society Clinical Practice Guideline, Endocrine Society, 2022, https://doi.org/10.1210/clinem/dgac278

TODO: consider adding scripts/calc.py for the es-preop-bg-only-target calculator