Hyperglycemia Protocol

Anesthesiologist’s Guide to Perioperative Glycemic Management 

PREOPERATIVE HYPERGLYCEMIA 

·         DM: 8.3% of the US population& 50% of them will require surgery

·         1/3 – ½ of DM2 patients don’t know they are diabetic at the time of surgery.

·         21% of noncardiac surgery patients without diagnosis of DM were hyperglycemic & half of them are diabetic

·         Preoperative BG > 200 increases 2.1-fold increase of overall mortality, 4-fold increase of CV mortality, poor wound healing, increased infection

·         BG is independent risk factor regardless of DM status

·         Hyperglycemic non-DM patients’ outcome is worse than DM patients’ of same BG level. But when euglycemic, non-DM patients do better than DM patients.

Table 1.  Diabetes Preoperative Medication Guidelines*

Diabetic Medication

Day before Surgery

Day of Surgery

Communication

Oral hypoglycemic

Continue same dose

Hold all

Nurse verifies if patient has taken any

Accu-Chek on arrival to preop

Noninsulin injectables

Continue same dose

Hold all

Nurse verifies if patient has taken any
Accu-Chek
on arrival to preop

 

Insulin pump

Follow insulin pump protocol

Follow insulin pump protocol

Nurse verifies insulin pump

Settings

Accu-Chek on arrival to preop

 

Long-acting insulin
(Levemir, Lantus, NPH)

Continue same dose

1/2 of the usual AM dose

 

Nurse verifies insulin taken

Accu-Chek on arrival to preop

 

Mixed insulin
(70/30 or 75/25)

Continue same dose

If  > 200 , 1/2 of the usual AM dose

If < 200, no insulin

 

Nurse verifies if insulin taken

Accu-Chek on arrival to preop

 

*Regimens and doses can be adjusted on the basis of clinical judgment and individual patient variables.

Table 2. Pre-op blood glucose control

Blood Glucose

Insulin IV Bolus

181- 200

2 units

201- 250

3 units

251- 300

4 units

301 - 350

6 units

> 351

7 units

* Recheck blood glucose in 30mins

MANAGEMENT OF DIABETIC PATIENTS WITH INSULIN PUMPS

·         Continue if surgery time < 1hr

·         D/C the insulin pump if surgery> 3hrs, expected exposure to CXR, CT, MRI or electric defibrillation

·         In PACU, check mental competency to resume the pump

INTRAOPERATIVE HYPERGLYCEMIA

·        Target: 140-180

·        Basal long-acting SQ insulin + insulin drip (i.e. ½ of usual AM Lantus preop + drip intraop) is the best strategy

·        NO body Wt or DM status adjustment

·        Higher glycemic variability, BG < 140 or > 200 is associated with worse outcome

·        SQ insulin is not reliable (Slow unreliable onset  b/o tissue circulation, perfusion, skin temp change by cold room & Bair hugger): only for long-acting insulin

·        Dexamethasone 8mg doesn’t affect DM patients’ BG significantly compared to non-DM patients’ intraoperatively

 

Insulin infusion

Blood Glucose (mg/dL)

Decreasing BG

Stable BG

Increasing BG

Unit

Unit/hr

Bolus

Rate

Bolus

Rate

Bolus

Rate

< 70

 

Hold,
D50 12.5 – 25ml

 

Hold,
D50 12.5 – 25ml

 

Hold,
D50 12.5 – 25ml

71 – 140

 

Hold

 

Hold

 

↓ 50%

141 – 180

 

Hold

 

No change

 

↑ 25%

181 – 200

 

↓ 25%

2

↑ 25%

2

↑ 50%

201 – 250

 

No Change

3

↑ 50%

3

↑ 50%

251 – 300

3

No Change

3

↑ 50%

4

↑ 50%

301 – 350

4

No Change

4

↑ 50%

5

↑ 50%

351 – 400

5

No Change

5

↑ 50%

7

↑ 50%

> 400

7

No Change

7

↑ 50%

10

↑ 50

: Decrease by                                                           : Increase by
 Decreasing BG: ↓ more than 30 in 30min           Increasing BG: ↑ more than 30 in 30min

1.      {C}{C} Recheck BG q30min with same method from same source (Recheck q5min if BG <70)

2.      {C}{C} Prime insulin tubing with 25ml of insulin solution

3.      {C}{C} MAX increase rate per change = 10 units/hr (round rates to nearest 0.5)

4.      {C}{C} Notify staff if BG <70 or >400

5.      {C}{C} If D50 is used, Accu-check q30min till BG >80 x3 consecutively

6.      {C}{C} If BG is between 141 -180 & stable x2 consecutively, BG can be checked q60min

7.      {C}{C} BG verification from alternate method for;
   - BG variation > 100 on consecutive measures
   - Suspicion of false results or contamination
   - BG reading is “Hi” or “Low”

8.      {C}{C} Rate may need modification on clinical decision

Initiation
 - 181 - 200: 2 units bolus & 2 units/hr
 - 201 - 250: 3 units bolus & 3  units/hr
 - 251 - 300: 4 units bolus & 4  units/hr
 - 300 - 350: 6 units bolus & 6  units/hr
 -     > 350   : 8 units bolus & 8  units/hr

POSTOPERATIVE MANAGEMENT OF GLYCEMIA 

·         Postop hyperglycemia is associated with infection, ARF, acute MI, longer stay in ICU/hospital and mortality

·         Basal + SSI is better than SSI only

·         Keep insulin drip if it’s ICU patient

·         Accu-check or other POC glucose measurements tend to overestimate actual BG