POLICY: To provide a standard protocol for NPO/Perioperative Insulin Dependent Diabetic
Management.
PURPOSE: The purpose of the protocol is to provide safe management of diabetic patients going to surgery.
PROCEDURE:
STANDARD CONTROL PROTOCOL
(A) The day before surgery, no solid food or non-clear liquids after 10:00pm. Clear liquids may be consumed up to two hours before surgery as written in the hospital NPO guidelines. A container of apple juice should be readily available on the floor for emergency consumption.
(B) Perform accucheck at 0500 for all inpatients, or perform on arrival to SDS for all outpatients. Inform patient of result and document result appropriately. (EX: BS = 120 at
0500 on 1/2/95).
(C)
Call Anesthesiology department at ext. 8105 to report only those results <80 mg/dl or
>250 mg/dl.
(D)
For diabetic patients going to surgery via SDS: No IV start or insulin administration to patients scheduled for 0715 starts unless the BS<80 mg/dl, (the anesthesia team will manage IV and insulin in preop receiving area). For all patients scheduled after 0715, and 0715 patients with BS<80 mg/dl, on admission to SDS start an
IV (20 g. minimum) with D51/2NS infused at 125 rnl/hr/70 kg.
(E) For diabetic patients going to surgery from a floor bed: Start an IV (20 g minimum) with
D5l/2N5 infused at 125 ml/hr70 kg. Do this at 0500 for 0715 cases and at 0600 for all other cases.
(1) The D5l/2NS infusions should be continued throughout surgery and in the
PACU postoperatively at the same rate. Fluid needed for volume repletion (at a faster rate or in a bolus) should not contain dextrose and should either be piggybacked into the continuous D5l/2NS infusion or should be given through a second IV.
(F) After starting the D51/2NS infusion, give one half of the patient's usual morning dose of regular and/or NPH insulin subcutaneously. Hold the insulin only if the accucheck was <80

MEDICAL STAFF POLICY:
NPO/PERIOPERATIVE INSULIN DEPENDENT DIABETIC MANAGEMENT
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2.0 mg/dl. If insulin was held for a low CBG, check the CBG 30-60 min. after the IV started. If then > 80 mg/dl, give insulin.
(G) For renal failure patients, start a heparin lock, but no continuous infusion. Give half of their
NPH insulin, but no regular insulin. Follow the rest of the protocol as written.
(H)
Patients with a history of renal insufficiency, an elevated creatinine, congestive heart failure, or a history of decreased left ventricular function, use DlOW at 5Occ/hr instead of
D51/2N5 at 125ml/hr/70 kg.
1.9 An accucheck must be performed no later than two hours after the insulin was given and Q2 hours until patient is out of PACU regardless of patient location. This includes in the OR and in the PACU. It is the primary responsibility of the nurse or doctor caring for a patient to be sure that the nurse receiving a patient in transport has clear documentation of insulin administration times and the time and result of all accuchecks and the necessary time for the next accucheck. An NPO diabetic flow sheet should be used.
1.10 Sliding scale doses of regular SQ insulin may be used beginning one to two hours after the original insulin administration only as ordered by the anesthesiologist before and during surgery, and in the PACU. Contact the patients primary care physician or surgeon for postoperative management (IVF's insulin accucheck) if specific orders are not on the chart. The usual Q4 hours accuchecks should be resumed immediately post-op or as otherwise specified by the patient's primary care or admitting physician. Call the endocrinologist only if the primary care physician consulted him.
TIGHT CONTROL PROTOCOL
2.1 NOTE: Intended for use in "brittle” diabetics, and in those patients with specific concerns where available data suggests potential advantage of keeping blood glucose <200 mg/dl: pregnant diabetic; diabetic undergoing cardiopulmonary bypass; those at risk for perioperative global CNS ischemia.
2.1.1 At 0500 the morning of surgery, determine blood glucose level
(accucheck) and document. Follow hospital NPO Guidelines. Do not give usual AM insulin.
2.1.2 After above, start an IV (20g min.) and begin an infusion of D5W at
50ml/hr/70 kg.
2.1.3 Next, "piggyback" to the D5W an infusion of regular insulin 2 50 units in
250 ml of 0.9% NS). Piggyback as close to the IV catheter as possible.
This must be set up on a pump. Before connecting the insulin line, flush the tubing with 60ml of the insulin solution and discard the flushing solution. This saturates insulin-binding sites in the tubing.
2.1.4 Set the infusion rate for the insulin using the following chart:
CBG (MG/D) INSULIN RATE
<125
125-210 off
1 unit/hr
211-275 2 units/hr

MEDICAL STAFF POLICY:
NPO/PERIOPERATIVE INSULIN DEPENDENT DIABETIC MANAGEMENT
276-350
351-425
426-500
>500
3 units/hr
4 units/hr
5 units/hr call MD for rate
The goal perioperatively is to maintain the BS<200 mg/dl. If the above rate protocol is not aggressive enough for a given patient, call
Anesthesiology Dept. for permission for a rate increase.
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2.1.5 Repeat accuchecks every 2 hours as needed, and adjust the insulin rate appropriately using the above chart to maintain blood glucose levels between 100 and 200 mg/dl. Rapidly changing glucose levels will require more frequent accuchecks for safe monitoring.
2.1.6 The above guidelines (sections 1.2 and 1.9) for documentation of insulin administration and accuchecks and communication with subsequent caregivers should be followed.
2.1.7 Volume repletion and electrolyte management should be done through a second IV as needed, and should be done with non-dextrose containing solutions. Some authors recommend non-lactate-containing solutions, as well.
2.1.8 Plasma glucose levels should be determined near the beginning of surgery and at least every two hours for the next 24-hour period. As stated above, adjust the insulin infusion rate using the chart given in 2.1.4 above after each accucheck.
2.1.9 If the blood glucose level is 50-60 mg/dl, give 10ml of D5OW IV push. If blood glucose level is 40-50 mg/dl, give 20ml D50W IV push. If blood glucose is <40 mg/dl, push one ampule of D5OW IV push. Twenty minutes after D5OW is given recheck the blood glucose. Follow the above orders again for abnormal glucose levels.
2.1.10 Follow the above instructions (section 1.10) on which physician to call with questions or problems with blood glucose management.
NOTE: An order (written or verbal) must be received to follow either the loose or tight control protocol. If such an order was not received, contact the physician who wrote the NPO orders for diabetic management orders.

MEDICAL STAFF POLICY:
NPO/PERIOPERATIVE INSULIN DEPENDENT DIABETIC MANAGEMENT
Name: ________________________________________
TIME INSULIN GIVEN AND
ROUTE
DBG OR BLOOD
BLUCOSE (mg/dl)
CAREGIVER (Document when receiving or transferring)
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MEDICAL STAFF POLICY:
NPO/PERIOPERATIVE INSULIN DEPENDENT DIABETIC MANAGEMENT
Date adopted by the Department of Surgery: October 20, 1999
Date adopted by the Medical Executive Committee: November 9, 1999
Date adopted by the Houston County Healthcare Authority: November 30, 1999
Revised/Reviewed: October 16, 2002
January 10, 2006
January 25, 2010
March 23, 2011
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