Plymouth Hospitals NHS Trust
Guideline for the management of blood sugars
in
PERI-OPERATIVE / FASTING / UNSTABLE
DIABETES IN ADULTS
Patient details (affix label)
Name: …………………………..
Hosp number: ………………….
DOB: ……./……/….…………..
General Principles
Type 1 / Insulin Treated Diabetes
 Omit usual dose of subcutaneous insulin on the morning of the operation.
 Start the insulin sliding scale and IV fluids on the morning of an operation.
 Monitor blood glucose 2 hourly.
 Maintain the patient’s blood glucose between 5 -10mmol/l.
Type 2 Diabetes
 Omit oral hypoglycaemics on the morning of the operation.
 Monitor blood glucose 2 hourly.
 Start insulin sliding scale & IV fluids if blood glucose is less than 5mmol/l or greater than 10mmol/l.
Unstable Diabetes
 Patients experiencing uncontrolled hyperglycaemia or hypoglycaemia.
 To discuss use of scale contact Diabetes Team (see details over).
Glucose control
 Any patient with diabetes should be first on the operating list.
 Monitor blood glucose hourly for 12 hours then 2 hourly if stable (hourly if unstable).
 Maintain the patient’s blood glucose between 5 and 10mmol/l, adjust insulin infusion rate as required.
 Insulin requirements increase in patients undergoing surgery and in patients with infections.
Electrolyte control
 Check blood electrolytes 12 hourly.
 It is important to avoid hyponatraemia (low Na+) and hypokalaemia (low K+).
 In addition to the glucose solution, most patients will require a second, separate infusion of 0.9%
normal saline solution to maintain a Na+ >135mmol/l.
Discontinuation of sliding scale regime
 Resume usual subcutaneous regime / oral therapy once patient is eating and drinking. Maintain
infusions for 30 minutes after starting usual S/C insulin or oral therapy, (unless Novorapid, Lispro,
Novomix 30, Humalog mixes in which case stop at time).
Intravenous fluid recommendations (prescribe on drug chart)
IV fluids (Guidelines only, fluid volume, type and potassium should be adjusted to patient’s
condition) In cases of renal impairment discuss treatment with renal specialist.
 IV Fluids must be prescribed on the IV prescription sheet on the back of the main prescription chart.
 Blood sugars < 15mmols 500ml bag of 10% glucose with 10mmol potassium chloride (unlicensed
product). Blood sugars > 15mmols use 0.9% Normal Saline.
 Infuse via a volumetric pump at a rate of 1ml/kg/hr (max 100ml/hr).
 All patients who have undergone major surgery must receive, in addition, a separate infusion of either
0.9% normal saline or gelofusine via a second cannula to meet their total fluid requirements.
Connections
 Connect the insulin line to the glucose administration set with a suitable Y-connector.
 This connector must contain anti-reflux and anti-syphon valves.
 Do not use a 3-way-tap.
 Do not give other intravenous drugs through the insulin cannula.
Transport
 When transporting patients to theatre, continue both insulin and glucose infusion pumps.
Dr P.K. Chong 10/05 Review date Oct 2007
Insulin sliding scale prescription
Prepare a solution of 50 units of Human Actrapid or Humulin S insulin with
49.5ml of 0.9% NaCl (i.e. 1 unit per ml)
Infuse using a syringe driver at a rate according to the table below. The infusion rates below are only a
guide and may need to be adjusted to satisfy the individual patient’s insulin requirements.
For advice contact the diabetes nurse on bleep 989 or the diabetes registrar on bleep106/205. After hours
the diabetes ward, Monkswell, can be contacted. (Ext 52960).
This prescription is only valid for 24 hours, after which the patient must be reviewed and another
prescription completed, if appropriate.
Blood glucose
Insulin infusion rate
Alternative prescription
(mmol / l)
(units / hour)
(If blood glucose > 16mmols over 4
hours)
<3.5
Inform Dr.,stop infusion for 30 mins then
0.5
3.5 – 6.0
0.5
6.1 – 10.0
1
10.1 – 16
2
16.1 – 20.0
4
>20
6 and inform doctor
Doctor’s signature:
Date:
Infusion preparation*
Date of preparation:
Type of insulin:
Time of preparation:
Batch No.of insulin:
Time discontinued:
Batch No.of N/S:
Nurse signature:
Witness signature:
Date of preparation:
Type of insulin:
Time of preparation:
Batch No.of insulin:
Time discontinued:
Batch No.of N/S:
Nurse signature:
Witness signature:
Human Actrapid / Humulin S
Human Actrapid / Humulin S
Administration details / patient observations (2 hourly**)
Date:
Time:
Blood glucose (mmol/l)
Insulin infusion rate (ml/hr)
Change to rate (↑↓ ml/hr)
Volume of insulin infused (ml)
Volume of IV fluid infused (ml)
Urine ketones
Na+/K+ (12 hrly)
Initials
*
Any insulin remaining after 24 hours must be discarded and a fresh solution prepared.
**
Observation details should be taken every 2 hours (hourly if unstable).