The new NHS Diabetes guidelines on the perioperative management of people with diabetes

much of what we do in our profession has been determined by evidence from large, long-term intervention trials. These provide a strong evidence base for recommending person specific targets for HbA1c, blood pressure and lipids. However, as diabetes specialists we also have an important role in ensuring that the condition is well managed during hospital admission and in this area there is very limited evidence on which to base recommendations. The incidence of diabetes is rising exponentially and as a consequence the number of inpatients with diabetes is also rising. Attention is therefore focusing on inpatient care, with recognition that this is frequently suboptimal. The 2010 National Inpatient Audit reports a mean diabetes prevalence of 15% (range 6.6–24.3%) among inpatients in acute hospitals.1 The audit shows that patients with diabetes experience high levels of medication and management errors and increased length of stay.1,2 Guidelines for the management of inpatients with diabetes are needed to standardise and improve care across the UK. Surgery in people with diabetes is a neglected area, with surgeons and anaesthetists often happy with the idea of ‘permissive hyperglycaemia’, assuming that short (or even long) term hyperglycaemia is less likely to do the patient harm than a hypoglycaemic episode while under anaesthetic. However, recent data from the US have demonstrated that people with diabetes undergoing surgery have an almost 50% greater chance of postoperative mortality than those with normal glucose tolerance and have adverse consequences in all measures of postoperative morbidity.3 Furthermore, people with preoperative hyperglycaemia, who were not previously known to have diabetes, had a risk of perioperative death up to 12 times that of people without diabetes, rising to 40 times if the hyperglycaemia persisted postoperatively.3 These are powerful data and if you could tell your surgical colleagues that you could reduce their perioperative mortality by 12-fold without them even putting knife to skin, you would probably get their attention fairly swiftly.