Peri-Procedural Management of Diabetes

Peri-procedure protocols are available on the wards (search for “C160011” or “C260110” on the CDHB intranet), but no single protocol will work for all patients, hence individualized treatment plans may be required, usually supervised by the Anaesthetist.

Note: These protocols may not be suitable in some specialty areas such as Nephrology. Seek advice.

If the C160011 and C260110 protocols are not suitable or accessible, here are some suggested regimens:

If patient has Type 1 diabetes, uses glargine (Lantus) insulin at bedtime, and is undergoing a procedure likely to result in only 1 missed meal, then give usual glargine dose on day before surgery, fast from midnight and omit meal-time rapid-acting insulin on day of surgery. Measure blood glucose 2 hourly pre- and post-operatively and every hour during surgery. The patient may need to commence a peri-procedure insulin infusion sliding scale if becoming hyperglycaemic (e.g., >11 mmol/L), at the discretion of the Anaesthetist. See table below.
If on insulin but not on glargine, omit morning subcutaneous insulin. Start IV fluids and an insulin infusion sliding scale (see table below). Measure blood glucose 2 hourly pre- and post-operatively and every hour during surgery.
If patient has Type 2 diabetes and is on oral hypoglycaemic medications, omit these. Restart when eating for at least 12 hours.
If the patient is on insulin (± oral hypoglycaemic medications), omit morning insulin and oral hypoglycaemic medications on the day of surgery. Measure blood glucose 2 hourly pre- and post-operatively and every hour during surgery. Only start an insulin infusion if the patient's glucose level rises above 12 mmol/L.


Peri-Procedure Insulin Infusion Sliding Scale IV fluid guidelines: 1000 mL bag sodium chloride 0.18% and glucose 4% with 30 mmol potassium chloride IV to run at 83 mL/hour (12 hourly) reviewed daily. Consider using Plasma-Lyte 148™ and 5% Glucose with prolonged infusion use. Prescription: 50 units Actrapid™ insulin made up to 50 mL with sodium chloride 0.9% IV to run according to blood glucose sliding scale below.
Blood glucose (mmol/L)	Insulin infusion rate
<3.5	Stop insulin infusion. Recheck the blood glucose after 15 minutes. If patient has clinical signs of hypoglycaemia (confused, semi- or unconscious) administer 50 mL of 50% glucose IV. Recheck glucose at 10 - 15 minute intervals. Recommence sliding scale insulin once blood glucose ≥4 mmol/L.
4	0.5 mL/hr
4.1 - 7	1 mL/hr
7.1 - 9	2 mL/hr
9.1 - 11	3 mL/hr
11.1 - 14	4 mL/hr
14.1 - 17	5 mL/hr. If persistently at this rate for 6 hours, for medical review.
17.1 - 20	6 mL/hr. If persistently at this rate for 6 hours, for medical review.
>20	For medical review. Consider DKA.

If there is any delay in the surgery or the patient does not resume normal intake promptly post-operatively, hyponatraemia may develop if this protocol is continued. Therefore sodium, potassium, and creatinine will need to be closely monitored, at least 12 hourly. Seek advice under these circumstances from the Diabetes Service.


Information about this CDHB document (1375):
Document Owner:	Blue Book Editorial Committee (see Who's Who)
Issue Date:	December 2013
Next Review:	December 2015
Keywords:
Note: Only the electronic version is controlled. Once printed, this is no longer a controlled document.
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Topic Code: 1375