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Perioperative management of hyperglycemia

Perioperative Management of Diabetic or new Hyperglycemia
For Vascular Surgery and Renal Transplantation Patients
(PAU-ASU-OR-PACU)
Target Blood Glucose 120 – 180 mg/dL
I. Target population:
x All patients undergoing Vascular Surgery or Renal Transplantation procedures
II. Pre-anesthesia Unit (PAU):

A. Advise patients to check fingerstick blood glucose at usual times. B. Patients currently treated with oral hypoglycemic drugs (see sample list, Table 1):
o Advise to stop these medications at 0001 day of surgery. Table 1. Oral hypoglycemic drugs *
Secretagogues
Biguanides
Thiazolidinediones Absorption Incretins
inhibitors
* exenatide (Byetta®) is given s.c., not orally, but is included for completeness Note: there are also various combinations of the above agents that are commercially
available (e.g. Avandamet, Metaglip, Janumet)
Page 1 of 13 FINAL VERSION_December 2, 2009 C. Insulin
o Basal insulin: (eg-glargine (Lantus®) and detemir (Levemir®)
1. Give the usual dose on the evening before surgery
2. Give the usual dose on the morning of surgery
o NPH insulin:
1. administer usual evening dose on the evening prior to surgery
2. reduce the morning dose by 50% on the day of surgery
x Note: NPH insulin may be part of a pre-mixed preparation (e.g. Humulin 70/30, Novolog Mix 75/25). In these cases, advise the patient to talk to their primary care doctor or endocrinologist about how much to reduce their dose prior to surgery. o Insulin Pump:
1. Patients treated with an insulin pump should be advised to continue their
basal insulin infusion until admission to ASU. Anesthesia provider to determine peri-operative pump utilization in conjunction with the patient. x Note: For longer procedures such as AAA, during which patients may develop significant fluid losses, conversion to IV insulin is recommended. The initial insulin infusion rate can be calculated using the total daily (24hour) basal dose divided by 24. x It is recommended the patient’s insulin pump be discontinued and replaced with a continuous insulin IV infusion if cognitive o Prandial (meal) insulin: (eg-Regular, aspart (Novolog®), lispro (Humalog®), or
o Correctional insulin:
1. VERIFY correction dose morning of surgery with primary care physician Page 2 of 13 FINAL VERSION_December 2, 2009 III. ASU: Target Blood Glucose 120 – 180 mg/dL
A. Complete medication reconciliation form to include when and how much insulin administered in the 24 hours prior to surgery. B. Check fingerstick BG prior to surgery and Q1h if prolonged for > 2 hours in ASU or Pre- C. All fingerstick BG results will be documented on the flowsheet. D. In Vascular patients, if the BG is > 180 mg/dL, it is recommended to give Regular insulin, either by hourly IM injection or by a continuous IV infusion, to maintain BG in 1. Follow hypoglycemia protocol for NPO patients 2. Notify anesthesia of blood glucose and treatment F. If ASU BG 180 – 300, notify anesthesia for treatment to maintain BG in target range 1. Regular insulin continuous IV infusion or G. IF ASU BG > 300, notify anesthesia for treatment to maintain BG in target range with: 1. Regular insulin continuous IV infusion or Page 3 of 13 FINAL VERSION_December 2, 2009 IV. OPERATING ROOM: Target blood glucose 120 – 180 mg/dL
A. If ASU BG > 180 AND/OR for all procedures expected to last > 2hrs check blood 1. Treat hyperglycemia to maintain blood glucose in target range with: 1. Preferred treatment is use of Regular insulin continuous IV infusion 1. may be given initially to lower elevated glucose, but is not recommended to give repeatedly to control glycemia 2. Treat hypoglycemia (<70 mg/dL) per protocol for NPO patient B. Document BG values and insulin administration dosing on anesthesia record C. The MMC IV Insulin Infusion Protocol is available for use, either in the form of a printed nomogram to use with hourly FSBG results, or as a computer-based calculator.
Page 4 of 13 FINAL VERSION_December 2, 2009 V. PACU Guiding Principals: Target blood glucose range 120 – 180 mg/dL
1. For the fed patient: when ordering insulin, use the Insulin Comprehensive Order Set to order basal, prandial and correctional insulin doses; this will include orders to monitor fingerstick BG tid-ac and qhs, to order a diabetic carbohydrate meal plan, and RN orders for adjustment of insulin doses based on estimated carbohydrate intake 2. For the NPO patient: when ordering insulin, use the Insulin Comprehensive Order Set to order basal and correctional insulin doses; this will include orders to monitor fingerstick a. Renal transplant patients should be treated with regular continuous IV infusion. b. Patients receive a steroid pulse which will result in hyperglycemia c. Insulin drip will infuse to maintain blood glucose 120 – 180 mg/dL x 48hours from 4. Basal insulin (glargine, detemir, NPH) Basal insulin should always be given to the patient even when not eating meals.
a. Patient previously diagnosed with diabetes who are on basal insulin: i. Order their basal insulin (glargine, detemir) at the usual times of day they would normally receive it. If on glargine or detemir once daily, the first post- operative dose should be given 24 hours after the previous dose. If on b.i.d. basal insulin regimen, the AM dose of insulin should have been given on the day or surgery, and the evening dose can be given at the usual time they would normally receive it (usually 2100 hr). b. Patients who have not previously been on basal insulin (previously undiagnosed diabetes, or diagnosed treated with diet and/or oral agents ony): i. Method of estimating basal insulin requirement is 0.2-0.4 units/kg. 5. Prandial insulin (when patient is eating meals)
a. If patient previously on subcutaneous insulin prior to meals, the same regimen can be continued in the hospital once the patient has started to eat meals. i. Nursing orders in the Insulin Comprehensive Order Set will advise the RN to give prandial insulin at the end of the meal, and to reduce the dose proportionately Page 5 of 13 FINAL VERSION_December 2, 2009 b. If patient was not previously on SQ insulin prior to meals, a prandial insulin dose can be calculated using the Insulin Comprehensive Order Set if it appears that the patient a. Use the Insulin Comprehensive Order Set to calculate Correction Factor insulin doses b. Correction Factor doses should be given to treat elevated BG (> 150 mg/dL) even in 7. IV insulin infusions (if present) should be terminated in PACU, and replaced with subcutaneous insulin injections. If the patient has received their basal insulin dose (glargine or detemir) within the previous 24 hours, it is not necessary to overlap the IV 8. If the blood sugar is outside the target range (120 – 180 mg/dL) contact the surgical team for orders. If the surgical team is unavailable, contact anesthesia for orders. Page 6 of 13 FINAL VERSION_December 2, 2009 VI. PACU Protocol for Insulin Treated Diabetic Patients: Target blood glucose 120 – 180
1. Obtain a finger stick blood glucose upon arrival into PACU A. If insulin NOT used in the OR:
if blood sugar is above or below target range, contact the surgical team for orders a. if the surgical team is unavailable, contact anesthesia for orders follow step 2 for fed or non fed patients outlined below B. If CONTINUOUS IV insulin infusion used in the OR:
if blood sugar is within target range, discontinue the insulin infusion if blood sugar is above or below target range, contact the surgical team for orders a. if the surgical team is unavailable, contact anesthesia for orders Check blood glucose 1 hour after insulin infusion is dc’d and then every 1-2 hours iv. follow step 2 for fed or non fed patients outlined below C. If INTERMITTENT insulin (IVP, IM or SC) is used in the OR:
if blood sugar is above or below target range, contact the surgical team for orders a. if the surgical team is unavailable, contact anesthesia for orders follow step 2 for fed or non fed patients outlined below STEP 2: Determine if patient is anticipated to eat within 24 hours
A. If patient is anticipated to eat within 24 hours use the Insulin Comprehensive Order
Give basal insulin per the patient’s home schedule. a. If the patient has been previously treated with basal insulin, glargine (Lantus) or detemir (Levemir), order these to be given at their usual times and doses Page 7 of 13 FINAL VERSION_December 2, 2009 (refer to the Medication Reconciliation form to determine when the next dose Give Prandial aspart insulin with meals titrating insulin to carbohydrates a. prandial doses should be held until the patient has demonstrated an ability to Administer correction scale insulin with meals and at bedtime for BG greater than a. Short-acting insulin preparations (Regular, aspart, lispro) should be given as Correction Factor doses to lower elevated BG concentrations B. If patient is NOT anticipated to eat within 24 hours use the Insulin Comprehensive
Give basal insulin per patient’s home schedule. a. If the patient has been previously treated with basal insulin, glargine (Lantus) or detemir (Levemir), order these to be given at their usual times and doses (refer to the Medication Reconciliation form to determine when the next dose should be given) Administer Regular correction scale insulin Q6hrs for BG > target range a. Short-acting insulin preparations (Regular, aspart, lispro) should be given as Correction Factor doses to lower elevated BG concentrations Page 8 of 13 FINAL VERSION_December 2, 2009 VII. PACU Protocol for NON Insulin Treated Diabetic Patients: Target blood glucose 120 –
1. Obtain a finger stick blood glucose upon arrival into PACU A. If insulin NOT used in the OR:
if blood sugar is above or below target range, contact the surgical team for order a. if the surgical team is unavailable, contact anesthesia for orders consider starting basal insulin per step 2 follow step 3 for fed or non fed patients outlined below B. If CONTINUOUS IV insulin infusion used in the OR:
if blood sugar is within target range, discontinue the insulin infusion if blood sugar is above or below target range, contact the surgical team for orders a. if the surgical team is unavailable, contact anesthesia for orders Check blood glucose one hour after insulin infusion is discontinued AND then every 1-2 hours based on clinical condition consider starting basal insulin per step 2 follow step 3 for fed or non fed patients outlined below C. If INTERMITTENT insulin (IVP, IM or SC) is used in the OR:
if blood sugar is above or below target range, contact the surgical team for orders a. if the surgical team is unavailable, contact anesthesia for orders consider starting basal insulin per step 2 follow step 2 for fed or non fed patients outlined below A. Suggest starting basal insulin in PACU if:
Page 9 of 13 FINAL VERSION_December 2, 2009 Give initial basal glargine dose as 0.2 – 0.4 units/kg body weight 1. IV insulin drip should be continued at a fixed rate for 2 hours after the initial
STEP 3: Determine if patient is anticipated to eat within 24 hours

A. If patient is anticipated to eat within 24 hours use the Insulin Comprehensive Order
i. Administer correction scale insulin with meals and at bedtime for BG > target ii. Short-acting insulin preparations (Regular, aspart, lispro) should be given as Correction Factor doses to lower elevated BG concentrations iii. Restart sulfonylureas when patient is tolerating PO intake iv. NO Metformin x 48 hours post op AND until the serum creatinine is normal (reference oral agents Clinical Decision Support Tool available in SCM) B. If patient is NOT anticipated to eat within 24 hours use the Insulin Comprehensive
i. Administer Regular correction scale insulin Q6hrs for BG > target range a. Short-acting insulin preparations (Regular, aspart, lispro) should be given as Correction Factor doses to lower elevated BG concentrations Page 10 of 13 FINAL VERSION_December 2, 2009 VIII. PACU Protocol for Stress Hyperglycemia (no prior Diabetes diagnosis): Target
1. Obtain blood glucose upon arrival to PACU A. If insulin NOT used in the OR:
i. if blood sugar is above or below target range, contact the surgical team for orders a. if the surgical team is unavailable, contact anesthesia for orders ii. follow step 2 for fed or non fed patients outlined below B. If CONTINUOUS IV insulin infusion used in the OR:
i. if blood sugar is within target range, discontinue the insulin infusion ii. if blood sugar is above or below target range, contact the surgical team for orders a. if the surgical team is unavailable, contact anesthesia for orders iii. check blood glucose one hour after insulin infusion is discontinued AND then every 1-2 hours based on clinical condition iv. If HgbA1c > 7, presume newly diagnosed diabetes 1. If HgbA1C > 7, consider hospitalist or adult internal medicine co-manage 2. If HgbA1C > 9, consider endocrine consult as outpatient v. Transfer patient to surgical floor when stable, with orders for blood glucose vi. follow step 2 for fed or non fed patients outlined below C. If INTERMITTENT insulin (IVP, IM or SC) is used in the OR:
i. if blood sugar is above or below target range, contact the surgical team for orders a. if the surgical team is unavailable, contact anesthesia for orders ii. If HgbA1c > 7, presume newly diagnosed diabetes 1. If HgbA1C > 7, consider hospitalist or adult internal medicine co-manage 2. If HgbA1C > 9, consider endocrine consult as outpatient iii. Transfer patient to surgical floor when stable, with orders for blood glucose Page 11 of 13 FINAL VERSION_December 2, 2009 iv. follow step 2 for fed or non fed patients outlined below STEP 2: Determine if patient is anticipated to eat within 24 hours
A. If patient is anticipated to eat within 24 hours use the Insulin Comprehensive Order
Administer correctional Aspart insulin with meals and at bedtime for BG > B. If patient is NOT anticipated to eat within 24 hours use the Insulin Comprehensive
i. Administer Regular correction scale insulin Q6hrs for BG > target range a. Short-acting insulin preparations (Regular, aspart, lispro) should be given as Correction Factor doses to lower elevated BG concentrations Page 12 of 13 FINAL VERSION_December 2, 2009 ADULT Hypoglycemia
Clinical Decision Support Tool
Prevention of Nocturnal Hypoglycemia In general, it is not necessary to give a bedtime snack for patients treated with basal (glargine, detemir) insulin. However, if bedtime BG is below target range AND above 70mg/dl: give a 15 gram CHO snack. Treatment of Hypoglycemia: The major risk of insulin therapy is hypoglycemia. Appropriate dosing and timing of insulin in relation to food intake should minimize this risk. All patients on insulin or other hypoglycemic agents should have the following treatment orders in the event of hypoglycemia. The hypoglycemia treatment guidelines will be ordered on every patient receiving insulin therapy. Patient Clinical Status
Treatment
(mg/dl)
50-69

Alert, taking PO
Give 15 gm of rapid or fast acting carbohydrates.
Recheck BG 15 minutes post treatment. If BG remains <
70mg/dl, repeat treatment every 15 minutes until BG >
69mg/dl
Alert, NOT taking PO
Give 12.5 gm (25ml) of D50 IVP
Recheck BG 15 minutes post treatment. If BG remains <
70mg/dl, repeat treatment every 15 minutes until BG >
69mg/dl
If no IV access, RN may administer 1.0 mg glucagon
IM, turn patient on side, recheck BG 15 minutes, may
repeat glucagon x1 if BG remains <70mg/dl

<70mg/dl
Not alert
Give 25 gm (50 ml) of D50 IVP
Recheck BG 15 minutes post treatment. If BG remains <
70mg/dl, repeat treatment every 15 minutes until BG > <50mg/dL Alert, NOT taking PO
If no IV access, RN may administer 1.0 mg glucagon
IM, turn patient on side, recheck BG 15 minutes, may
repeat glucagon x1 if BG remains <70mg/dl

<50mg/dl
Alert, taking PO
Give 30 gm of fast acting carbohydrates.
Choose one of the following:
Recheck BG 15 minutes post treatment. If BG remains <
70mg/dl, repeat treatment every 15 minutes until BG >
69mg/dl
Notify physician of BG 50-69mg/dl that does not respond to treatment.
Notify physician of BG <50 mg/dl.

Page 13 of 13 FINAL VERSION_December 2, 2009

Source: http://www.theapms.com/topicpages/_vti_cnf/Docs/Vasc_Periop%20Glycemic%20Mgmt%20Protocol_FINAL_12.03.09.pdf

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