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Management Of The Diabetic Patient Going For Surgery

General Goals of Glycemic Control:

Avoidance of marked hyperglycemia

Avoidance of hypoglycemia

Maintenance of fluid and electrolytes balance

Prevention of Keto-acidosis

Diabetes management should be individualized based on patient


condition

Intravenous Fluid
1. If blood glucose 14 mmol/L, start with normal saline or
normal saline as appropriate.
2. If blood glucose <14 mmol/L, start or switch to D5% N.S or D5
N.S 85-125 cc/hr.
3. If fluid restriction is needed, then use D10% W or D10% N.S or
D10 N.S: 40-50 cc/hr (e.g. in CHF, ESRD, low E.F).
4. The other I.V drips (e.g. antibiotics, dopamine, etc) should be
taken into account as I.V. fluids and can be given as Dextrose,
normal saline, or normal saline as appropriate.
5. Start IV fluid on the day of the surgery in the morning.
DM (2) Treated With Diet Alone

Supplemental insulin sliding scale s.c short acting insulin ( FBS


<= 7 mmol)

I.V Glucose insulin- potassium infusion ( FBS > 7 mmol)

Intravenous fluid ( D5% NS or 1/2 NS )

Infusion rate : 85 125 ml/hr

Type 2 Diabetes Treated with Oral Hypoglycemic Agent and or


Incretins:

Sulfonylurea, - glucosidase inhibitors, thiazolidinediones (TZD),


and Incretins to be discontinued on the day of surgery.

Biguanides (metformin) to be discontinued on the day of surgery.


However, if patient is undergoing surgery with IV contrast then it
should be put on hold one day before surgery and restarted 48
hrs post op if patient stable and eating and passing urine with
normal renal function.

Dextrose I.V with supplemental (sliding scale) insulin s.c insulin


(FBS <=5 mmol)

I.V Glucose insulin potassium infusion (FBS >5 mmol)

Starting Insulin in the Hospital (Pre and post-operative care in


patients on oral feeding)
Patient Previously on Oral Agent

Consider an 24-hour insulin dose of 0.5 units/kg/day

Give 50% of this as basal :


1) Glargine or detemir once or twice daily
2) NPH 2-3 times daily

Give 50% for (aspart or lispro or regular) with meals if eating:


1) Apportion according to relative meal size
2) Can give after the meal if intake uncertain

Use supplemental (sliding scale) insulin scale and adjust

Check blood sugar pre meals and at bed time.

DM previously on Insulin

May need to switch long acting insulin Lantus to intermediate


acting insulin (NPH) 1-2 days before surgery.
Admission before surgery to control blood sugar.

Reduce the total dose of insulin by 20-30% if diabetes is well


controlled

Early surgery on the day of surgery

Insulin infusion (short acting insulin drip) for:


1. Complex, prolonged surgery
2. Emergency surgery while in DKA or NKH
3. Unstable DM (1)
4. Patients on insulin pump

Glucose- insulin- potassium infusion for others

Supplemental subcutaneous insulin scale

Supplemental SC Insulin Scale (referred to as Sliding Scale


insulin)
(Supplemental to diet, OHA, TPN, NG feed or SC or IV insulin)
B.S check every 4 hrs pre-operatively (on I.V fluid or TPN) and Q
1-2 hrs during surgery and Q 6hrs post-op
-

If eating: B.S before each meal and bed time


Blood glucose
(mmol/L)
10-12
12.1-14
14.1-16
16.1-18

Regular insulin
Protocol-1
4
6
8
10

Regular insulin
Protocol-2
6
8
10
12

Regular insulin
Protocol-3
8
10
12
14

18.1-20
20.1-22
>22

12
14
16
14
16
18
Call MD, Give 14 U regular S.C and check BS in 3-4
hr, if not better give insulin I.V infusion and check
lytes and bicarb and ketone level if DM (1) or
sepsis or critical patient.

Call MD if BS less than 5 mmol/l


To start with protocol 1. If RBS is not improving after 4 hours
then use protocol 2 and if after 4hrs not improving use
protocol 3.

Glucose insulin potassium infusion IV : GIK

Dextrose 5% normal saline or 0.45 normal saline (500 ml) with regular
insulin I.V with or without KCL.
Run at 85 125 ml/hr

Check KFT + Na + K before starting IV fluid


FBS (mmol)

Actrapid

<5

Non ( call MD if DM (1)

57

5-7U

7.1 10

8-9U

10.1 12

10 U

12.1 14

12 U (+) regular insulin 4 U subcut stat

>14
urgent).

Call M.D ( May need to delay surgery if not

Check B.S Q 1 hrs during the surgery

Post-OP : B.S check Q 6 hrs plus supplemental regular SC( sliding


scale) regular insulin.

When tolerates oral diet, stop I.V fluid and resume the pre-operative
diabetes management.

Insulin infusion
1. I.V. insulin solution: 250 units regular insulin in 250 ml of 0.45% saline
( N.S).
2. Measure blood sugar Q hourly until stable (6-10 mmol) for 4 readings
and then Q 2 hours.
3. When patient is stable and maintenance insulin (S.C) is given, insulin
I.V drip should be stopped 2 hours after the first S.C dose insulin.
Monitor K, Na, phosphorus and replace or treat as appropriate

Separate Glucose IV and Insulin Infusion


(Used in ICU Setting) using regular insulin infusion.

- Check blood glucose every 1-2 hr


- Guidelines for rate of insulin infusion
Blood glucose (mmol)
<7

U/hr
0

Bolus
0

7.1 - 9

9.1 - 11

11.1 - 13

13.1 - 15

15.1 17
17.1 - 19

5
6

6
8

19.1 - 21

10

> 21

10

12

If B.S < 5 , stop insulin, give I.V bolus 50% ml (25 ml) and modify
the drip.

Modify the algorithm for obesity, hepatic disease, sepsis,


steroid,TPN, renal transplant and CABG. (multiply the dose by
1.5-2)

In DM(1): if B.S 5-7 mmol/l, give low dose insulin, e.g 0.5 U/hr.

2)

Addition of regular insulin to TPN

Add of the current total dose of insulin (in 24 hrs) to TPN

Supplement with S.C regular insulin every 4 hours as follows


( see below)

Apply separate regular insulin infusion drip if available instead of


adding insulin to TPN bag.
Blood glucose

Regular insulin SC

10 12 mmol

4U

12.1 14 mmol

6U

14.1 16 mmol

8U

16.1 18 mmol

10 U

18.1 - 20 mmol

12 U

20.1 - 22 mmol

14 U

More than 22 mmol

Call MD

Less than 5 mmol

Call MD

Calculate the total regular insulin S.C given in 24 hrs and add it
to the next TPN bag.

Patients on Tube Feeding (TF)


Continuous TF
1)

Variable rate insulin infusion (if available, e.g in ICU )


Basal insulin (modified for stress)

1 U/hr

Continuous TF (100 ml/hr)

2 U/hr

Total dose

3 U/hr

2)
Basal long acting or NPH every 12 hrs in addition to S.C regular
insulin Q4 hrs.
When start subcutaneous insulin give 2/3 of total insulin infusion
required in the previous 24 hours.

Bolus Tube Feeding:

Bolus times (7 a.m., 11 a.m., 3 p.m., 7 p.m., 11 p.m.)

Calculate total dose of insulin

Give 60% of total dose as basal once daily or bid or NPH insulin
in divided doses ( of the dose at 7 a.m. and of the dose at 7
p.m.

Give 40% of total dose as regular insulin S.C divided in 2-3 doses
(7 am, 3pm, 7 pm) or rapid acting insulin before each feed.

Supplement with S.C regular insulin at the bolus times.

Review B.S readings every 24 36 hrs and modify the doses and
B.S frequency.

Good communication between the Surgeon, Dietitian, Nurses and


Diabetologist when changing the feeding or TPN.

Possible Strategy to Get off Insulin Regimen with DM2:


When total insulin dose is <0.5U/kg/24hours:
1- Return to previous oral therapy if patient had been well controlled
(A1C<7%), plus continue supplementary insulin scale.

Or
2- Continue basal component plus supplement insulin scale and add
previous oral agent if patient had an A1C is between 7-9%

Discharge Medication Algorithm


Discharge Treatment

A1C<7
%

A1C 7%9%

Re-start
outpatient
treatment
regimen (OAD
and/ or insulin)

Re-start
outpatient oral
agents and
Discharge on
glargine once
daily at 50% of
hospital dose

A1C
>9%
Discharge on basal
bolus at same
hospital dose.
Alternative regimen:
Re-start outpatient
oral agents and
Discharge on
glargine once daily

Prepared by:
Dr. Ibrahim Al-Janahi
Dr. Sara Darwish
Dr. Mahmoud Zirie
Dr. Mohd Al Bashir
References:
1)
2)
3)
4)
5)

The Endocrine Society


The American Diabetes Association
The American Association of Clinical Endocrinologists
The UpTodate
Local Practice at HMC