Glycemic Control, aka
Blood Glucose Management at MMC

Updated February 7, 2014
Author: from MMC Protocols

Description: Peri-Operative Management of blood glucose, in diabetic and non-diabetic patients at MMC Bramhall and SSC

For Mercy Hospital Protocol, click here


Targets & Goals

Target Population: All patients undergoing Vascular Surgery or Renal Transplantation procedures
Goal: maintain Blood Glucose between 120 – 180 mg/dL


Pre-Admission Instructions to Patient

Pre-Admission Unit (PAU): Tells Patient to:

    1. Do Finger-Stick Blood Glucose Checks At Usual times
    2. Stop Oral Hypoglycemics at 0001 hrs on Day of Surgery
    3. Insulin Management:
      1. Basal insulin: (e.g., glargine (Lantus®) and detemir (Levemir®)
        1. Administer the usual dose on the evening before surgery
        2. Administer the usual dose on the morning of surgery
      2. 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
      3. Insulin Pump:
        1. Continue basal insulin infusion until admission to ASU. Anesthesia provider to determine peri-operative pump utilization in conjunction with the patient.
      4. Prandial (meal) insulin: (eg-Regular, aspart (Novolog®), lispro (Humalog®), or glulisine (Apidra®)).
        1. Hold on the day of surgery.
      5. Correctional insulin:
        1. VERIFY correction dose morning of surgery with primary care physician or endocrinologist

ASU on Day of Surgery

ASU on Day of Surgery: Target Blood Glucose (BG) 120 – 180 mg/dL

  1. Determine total insulin dose in the 24 hrs prior to admission. (nursing)
  2. Fingerstick BG on admission: repeat q1h if delay in surgery. Document on Flowsheet.
  3. Management based on BG:
    1. BG <70 or patient is symptomatic:
      1. Follow hypoglycemia protocol for NPO patients
      2. Notify anesthesia of blood glucose and treatment
      3. Maintain BG in target range
    2. BG 71-180: No treatment. Monitor as in "B"
    3. BG 181-300:
      1. Regular insulin continuous IV infusion, or
      2. Regular insulin IM Q1 hour, or
      3. SC Aspart Q 3-4 hours
    4. BG >301: Notify Anesthesiologist
      1. Regular insulin continuous IV infusion, or
      2. Regular insulin IM Q1 hour

 

For longer procedures such as AAA, during which patients may develop significant fluid losses, conversion to IV insulin is recommended. The initial insulin hourly infusion rate can be calculated using the total daily (24hour) basal dose divided by 24.

It is recommended the patient’s insulin pump be discontinued and replaced with a continuous insulin IV infusion if cognitive impairment may be experienced.


Intra-Operative Management

Target Blood Glucose (BG) 120 – 180 mg/dL

If ASU BG > 180 or for case >2hrs: check blood glucose Q1 hour

Treat hyperglycemia to maintain blood glucose in target range with:

  1. Regular insulin continuous IV infusion or
  2. Regular insulin IM Q 1 hr, or
  3. Regular insulin SC Q 1 hr, or
  4. Regular insulin intravenous push
  5. Treat hypoglycemia (<70 mg/dL) per protocol for NPO patient

Document BG values and insulin administration dosing on anesthesia record

The MMC IV Insulin Infusion Protocol is available for use, either in the form of a

  1. printed nomogram nomogram to use with hourly FSBG results, or as a
  2. computer-based calculator, on the Desktop of Anesthesia OR Computers

PACU to Disposition/Discharge

Target Blood Glucose (BG) 120 – 180 mg/dL

PACU-to-Discharge Blood Glucose Management is managed by the Surgical Team.

With the exception of Renal Transplant and certain vascular patients, IV insulin infusions (if present) should be terminated in PACU, and
replaced with subcutaneous insulin injections, using the Insulin Comprehensive Order Set.


NomoGram for IV Insulin Infusion

from Archives of Surgery 2008, Kramer et. al

Insulin Nomogram (pdf)

MMC Insulin Infusion Protocol Assistant Is an app on every Anesthesia OR Computer Desktop


Hypoglycemia Management

follow the MMC Protocol for Hypoglycemia Management (pdf)


References

Maine Medical Center Complete Protocol for Glycemic Mgmt. of Vascular & Renal Transplant Patients (pdf)

Archives of Surgery article 2008, R Kramer MD (pdf)

Common Oral Hypoglycemics: