Sample Guidelines: Preoperative/Preprocedure Glucose Management for Patients with Known Diabetes

Sample Guidelines: Preoperative/Preprocedure Glucose Management for Patients with Known Diabetes

Diabetes Management Service [insert pager number] (for surgical patients)

Endocrine Consult Service [insert pager number] (for medical patients)

The following guidelines apply to most patients. Some special situations are discussed. However, the advice of the patient’s primary care provider (PCP) or endocrinologist should take precedence over these recommendations. In urgent or unusual cases, the Diabetes Management Service (DMS) or the Endocrine Consult Service may be contacted for advice. Guidelines for patient medications following procedures are also available.

1. 
   Obtain A1C if none available in last 90 days as this will assist discharge planning for patient.
   
2. 
   For non-insulin agents (oral or injectable)
   
   1. 
      For the day prior to procedure, patient to take usual doses
      
   2. 
      For the day of procedure, patient not to take any anti-diabetic non-insulin medication
      
3. 
   For insulin
   
   1. 
      For the day prior to procedure, take usual doses in the morning and evening (see below)
      
   2. 
      For the day of procedure, take 50% of basal insulin and no prandial insulin (see below)
      

Basal* insulin at night	Basal*insulin in the morning	Prandial** insulin in the morning
Give 100% of the dose	Give 50% of the dose	Hold

*Basal: NPH insulin, glargine (Lantus or Toujeo), detemir (Levemir), degludec (Tresiba)

**Prandial: aspart (Novolog), lispro (Humalog), glulisine (Apidra), regular human (Humulin R, Novolin R)

Special situations

1. 
   Patients on a “premixed” insulin
   

1. 
   Mixed insulin¹ [70/30, 75/25, 50/50]
   
   1. 
      PM dose (evening before procedure)
      
      1. 
         Administer the full PM dose
         
   2. 
      AM dose
      
      1. 
         Do not take insulin at home
         
      2. 
         Patient to bring insulin to hospital and administer 1/3 of usual morning dose upon arrival to the hospital or 1/3 of usual total morning dose will be administered on arrival in procedural area as NPH (this must be ordered by clinician)
         
1. 
   Insulin pump
   
   1. 
      Please refer to [insert hospital name] Insulin Pump Policy [insert link]
      
   2. 
      Patient must bring all pump supplies to the hospital
      
   3. 
      Infusion site selection: patient will discuss infusion site with surgeon, if applicable, to ensure avoidance of operative site
      
   4. 
      Procedures anticipated to last <4 hours
      
      1. 
         Patient may continue using insulin pump infusion during and after operation / procedure
         
      2. 
         Patient should maintain basal rate setting as suggested by his or her endocrinologist
         
      3. 
         Patient should chose infusion site that will not interfere with procedure
         
   5. 
      Procedures anticipated to last >4 hours
      
      1. 
         Patient should continue pump infusion until procedure begins
         
      2. 
         Anesthesiologist or interventional physician will determine if pump use will continue throughout procedure or if patient will be converted to iv insulin drip or sc insulin during procedure
         
      3. 
         If detailed instructions for pump-to-subcutaneous conversion are not available from the patient’s physician, please consult Diabetes Management Service (surgical patients) or the Endocrine Consult Service (all other patients) for management
         
2. 
   Patients on continuous iv insulin infusions
   
   1. 
      When care of a patient on a continuous insulin infusion is transferred to a nurse not trained on insulin infusion protocols (i.e., interventional radiography, cardiovascular diagnostic and interventional center, angiography, operating room), or the patient is transferred to any situation where the trained nurse will not be able to follow the continuous insulin protocol as written, the following is recommended: Prior to the patient leaving for the procedure, notify the covering physician that the continuous insulin infusion cannot be continued
      
      1. 
         Stop the continuous insulin infusion before patient leaves for the procedure
         
      2. 
         If procedure is expected to last more than 2 hours
         
         1. 
            Request a times one order for subcutaneous regular insulin
            
            1. 
               Dose equivalent to last hour’s drip rate (i.e., if insulin infusion at 5 units/hr during last hour, dose is 5 units) up to 10 units max
               
      3. 
         For management of patient during procedure, please refer to [insert hospital name] Guidelines for Perioperative/Periprocedure Management of Patients with Diabetes [insert link and name of relevant hospital guidelines]
         
      4. 
         Discontinue sliding scale and resume the continuous insulin infusion, from the beginning of the protocol, upon returning from the procedure
         

4. 
   “Bowel Prep” (Clear Liquid Diet and Laxative Use) for colonoscopy or colonic surgery
   
   1. 
      Day of bowel prep
      
      1. 
         Glucose monitoring and nutrition
         
         1. 
            All patients should test glucose levels several times during the day of bowel prep
            
         2. 
            Blood glucose <100 mg/dL
            
            1. 
               Consider consuming clear liquids or Jell-o® with sugar
               
         3. 
            Blood glucose >200 mg/dL
            
            1. 
               Consider consuming sugar-free liquids or Jell-o®
               
      2. 
         Medications for day of bowel prep
         
         1. 
            Discuss with PCP or endocrinologist all adjustments in medications for diabetes, including oral agents, injected medications, insulin, and pump settings
            
   2. 
      Day of procedure
      
      1. 
         Refer to appropriate sections for “day of procedure” outlined at beginning of guideline
         

1¹This recommendation only concerns patients who are outpatients prior to the operation / procedure. Mixed insulins are not available on [insert hospital name] formulary.

Shared by ASHP Advantage Dec-15

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