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Department of EndocrinologyAmrita Institute of Medical Sciences

Strategies for blood glucose control in the hospital

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Points to be discussed

• Preoperative Mgt of DM in Endo OPD

• BG control after admission

• Perioperative management

• Transition from Insulin Infusion to S/c

• Plan on discharge3

Preoperative Mgt of DM in Endo OPD

• Type and nature of surgery

• Present anti diabetic Rx

• Associated complications/ co morbidities

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To give fitness for surgeryTarget Cut offs :

FBS < 130 mg/dl

PPBS/RBS <200 mg/dl

Role of Hba1c :

< 8 fit for surgery

> 8 <10 control BG and take up for surgery

> 10 postpone surgery if not an emergency 5

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Minor Surgery

Local anesthesia

No change in meal pattern

No change if DM is controlled

If grossly uncontrolled follow major Sx regimen

Minor Surgery -if patient comes fasting in the morning

• No change of– Metformin– TZD– Incretin/ DPP IV

( Glycomet, diabeta, glyciphage, obimet, pioz, piomed, januvia, jalra, zomelis)

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If on a Secretagogue(glibenclamide, glicalzide, glipizide. Meglitinides)• Omit morning dose on the day of surgery• FBS• < 80: 5% dextrose infusion 100ml/hr; monitor BG

after 2 hours• 80-200: No action• > 200 : 4 units regular insulin s/c and monitor BG

after 2 hours• > 300 Call the Endo team

• (Daonil, Glynase, Amaryl, Glimy, Dianorm, Diabend, Euglucon)

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Minor Surgery -pts on Insulin, Check FBS

• < 80: 5% dextrose infusion; monitor BG after 2 hours

• 80-200: No action

• > 200 : 1/2 the morning dose of whichever insulin the patient was receiving s/c and monitor BG after 2 hours

• > 300: Call the Endo team 9

Major Surgery

General Anesthesia

Change in meal pattern

Hospitalization

Pt reaches ward in the evening 2 days preceding surgery

– Except patients who are already on insulin and are well controlled

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PAC

• When to refer for better blood glucose control

• HBA1c > 8 and/or

• RBS > 200

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Major Surgery

• After admission, BG control with Insulin only• Metformin containing drugs : stop 48 hrs

before

• All other OHAs: stop 24 hrs before

Do not start sliding scale

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Normal Pancreas Delivery of Insulin

Types of InsulinBolus Short acting Regular Insulin: (6-8 hrs)

Eg: Huminsulin R/ Human Actrapid /Insugen R Rapid acting analogues: (4-6 hrs)

Eg: Lispro, Aspart, Glulysine Humalog, Novorapid, Apidra

Basal Intermediate acting NPH insulin: (12-14) hrs

Eg: Huminsulin N/Human Insulatard Long acting analogues: (24) hrs

Glargine (Lantus), Detemir (Levemir)14

Types of Insulin

Premixed Insulin• 30 % Regular and 70 % NPH

Eg Mixtard 30/70,

Humisulin 30/70,Insugen 30/70• 50% regular and 50 % NPH

Eg Mixtard 50/50

Premixed analogues

Eg Novomix, Humalog Mix

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Typical insulin injection profiles

8 10 12 14 16 18 20 22 24 2 4 6 8

Time

Breakfast Lunch Evening mealShort-acting insulin injection

Long-actinginsulin injection

2 x daily

3 x daily

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Does anyone know how to make insulin work backwards?

How can you treat the past?

S/C Sliding Scale –still being practiced

Short acting Insulin S/C 6 or 8 hourly according to blood sugars

Origin - unknown

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Advantages

Doctor can write and forget it

Easy for the Nurses

Disadvantages

Unphysiologic

Does not consider post meal glucose excursion

More hypos and hyperglycemias

Roller coaster BS control

Quaele et al 1997

Dangerous for Type 1

S/C Sliding Scale

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10pm 340 24u Actrapid

Roller coaster blood sugar control while on sliding scale alone - an example

6am 72 -

12pm 356 24u Actrapid

3pm 53 sugar tea given

7pm 102 -

10pm 462 30u plain insulin

2am 35 25%dextrose given

A patient on Huminsulin30/70 at home

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Start all patients on Basal Bolus Insulin

Insulin Sensitive: 0.3 U/kg/dayelderly, cachectic, renal and liver failure, patients with poor oral intake or NPO, stress hyperglycemia

Usual 0.5 U/kg/day for most patients who are expected to eat all or most of their meals

Insulin Resistant:0.75 U/kg/day Receiving glucocorticoids Obesity (BMI >30 kg/m2) Diabetics receiving >80 units/day of insulinPatients uncontrolled with “usual” dose

Basal-Bolus regimen

• 25 % Basal - as one NPH at night

• 75 % Bolus - as three premeal short acting or regular insulin

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Pts already on insulin regimens other than basal bolus and are well controlled

• Continue same regimen until the day before surgery

• Need to be admitted only a day before

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Monitoring

• 3 Premeals and bed time• Premeal Target < 130• Post meal if checked < 180 • Premeal cut off to give insulin

– 90-150 give scheduled dose– 70-90 reduce by 2-4 units– < 70 call Endo team– > 150 (>2) Call Endo team

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On the day of surgery

• Get FBS and Lytes• If FBS > 180 start on Insulin infusion; NS 100

ml/hr*• Start 10 % dextrose infusion once BG < 180• If FBS < 180 Start on 10 % Dextrose 100 ml/ hr*• ( Use DNS if patient has Na < 130 )• Start Insulin Infusion when BG > 180

*In patients with cardiac failure, renal failure and/or fluid overload, the concerned doctor should decide on the rate of infusion

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Insulin Infusion

• Starting Rate:• Start infusion at a rate – Blood sugar

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e.g: 346 = 3.46 = 3.5 u/hr

426 = 4.26 = 4.3 u/hr

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Insulin Infusion (Contd)

• Check GRBS hourly – Try to maintain blood sugar within a Target range: (120 – 180)

• if blood sugar is higher than target range – increase the rate every hour.• If blood sugar is within target range – Continue same rate• If blood sugar is lower than 120 – Reduce rate• If blood sugar < 80 – Stop infusion – give 25%

dextrose – Check RBS 30 minutes, later.

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Changing the ratedepends on current infusion rate

• Current Rate Change• <2 u/hr 0.5u• 2-5 u/hr 1u• 5-10 u/hr 2u• > 10 u/hr 3u

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Addition of K to 10% Dextrose

• S K < 3.5 add 20 meq to each pint• S K 3.5-5.5 10 meq to each pint• S K > 5.5 no K needed

• Be careful in patients with renal failure

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Intraoperative

• Managed by the anesthetist

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Post Operative: shifted to ward

• Plan:To restart the same insulin regimen the patient was on preoperatively

• Check a GRBS on arrival• If meal is delayed / there is no scheduled insulin at that

time – give 4 units regular insulin if GRBS > 250

• If Oral nutrition started immediately– Routine bolus along with the mealDo not use the sliding scale

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Post operative: shifted to ICU

• Continue 10 % dextrose and insulin infusion similar to preop protocol

• Depending on whether patient is started on NG/Jejunal feeds / TPN, shift to the corresponding protocol

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NG/Jejunal Feed protocol

• Basal bolus with 3 short acting and 2 long acting

• Usual patient 0.5 u/kg

• Insulin sensitive (includes pts who are just initiated on feeds with 30ml/hr) 0.3 u/kg

• Insulin resistant 0.75 u/kg

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NG/Jejunal Feed protocol

• 40 % bolus

• 60 % basal

• Bolus should be followed compulsorily by a feed in 30 minutes

Individual modification may be needed based on the quantity/quality/frequency of the feeds

Suggested protocol for pts on TPN

• TPN used in AIMS are

1. KABIVEN(mostly)-administered via central line and

• 2.TNA peri-administered via peripheral line

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Suggested protocol for pts on TPN

• Patients on TPN are generally sick and hence best initiated on insulin infusion protocol.

• Once the total requirement is made out, they can be shifted to Bolus 40% and basal 60% regimen

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Transition protocol

To be used when a patient is switched from IV Insulin Infusion to a SC Regimen

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STEP 1:

• Check the following:• A.Is the patient is starting on usual diet/soft diet/liquids only?

• B. Is Dextrose infusion is being continued when SC Insulin is to be started?

• C.Is the patient on NG feeding/

• D.Is the patient on Steroids?

• E.Has the average blood glucose in the preceding 12 hours has been at target ( 120-180 mg ) or above target(>180 mg)?

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STEP 2:

• Calculate the total insulin needed for the preceding 24 hours from the Insulin Infusion rate.

• Example:• Calculate the average Insulin Infusion rate for

the preceding 12 hours (Add all the rates for 12 hours before and divide by 12)

• Multiply this value x 24 to get the total 24 hour insulin requirement

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STEP 3:• Give half of this 24 hour requirement as basal

Insulin (long or Intermediate acting Insulin)

• Divide the remaining half into three doses and give SC before the three main meals(Prandial or Premeal Insulin. Use ONLY short acting Insulin for this purpose)

• Basal Insulin should be given 1 hour before stopping Insulin Infusion, if meal is delayed

• If infusion is being stopped at the time of a meal give the bolus only and stop infusion after 30 minutes. 39

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Insulin at discharge following major surgery• Current requirement <_ 0.5 units/kg/day

Shift to premixed insulin ( Human Mixtard/ Huminsulin 30/70 ) twice daily

• Current requirement > 0.5 units/kg/day

Send on basal bolus

All patients to be taught insulin injection technique by the staff

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Changes proposed for patients undergoing major surgery • PAC to include HBA1c and RBS as routine in all DM

patients• Refer for BG control when HBA1c > 8and/or RBS > 200• All patients to be admitted 2 days before • (except patients on insulin and well controlled for whom

no change in regimen is planned )• Stop metformin 2 days before and all other OHAs 1 day

before• Start on basal bolus insulin, do not use the sliding scale

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Changes proposed for patients undergoing major surgery

• Preop dextrose and insulin infusion for all patients on the day of surgery

• Intraoperative monitoring • Post operatively, continue preop insulin regimen

and monitor• Targets: Premeal < 130 Post meal < 180• 3 consecutive BG above target, call endo team• All patients to be taught insulin injection technique

and monitoring with glucometer in the ward by staff before discharge

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Changes proposed for patients undergoing major surgery

• Insulin to be given only in the abdomen(unless contraindicated) and boluses at least half an hour before meals

• Discharge patients on insulin • ( May be shifted to OHA on a case to case basis) • Follow up and monitoring plan should be included

in the discharge summary• Please call Endo team sufficiently early (ideally 2

days) before discharge in case of any help

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Team Endo is always available for help

Thank you

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