1. Department of Endocrinology
Amrita Institute of Medical Sciences
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2. Strategies for blood glucose control
in the hospital
2

3. 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 discharge
3

4. Preoperative Mgt of DM in
Endo OPD
• Type and nature of surgery
• Present anti diabetic Rx
• Associated complications/ co morbidities
4

5. To give fitness for surgery
Target 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

6. Minor Surgery
Local anesthesia
No change in meal
pattern
No change if DM is
controlled
If grossly uncontrolled
follow major Sx regimen
6

7. 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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8. 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)
8

9. 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
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10. 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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11. PAC
• When to refer for better blood glucose control
• HBA1c > 8
and/or
• RBS > 200
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12. 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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13. Normal Pancreas Delivery of Insulin
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14. Types of Insulin
Bolus
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)
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15. 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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16. Typical insulin injection profiles
Short-acting insulin injection
Breakfast
Lunch
Evening meal
Long-acting
insulin injection
2 x daily
3 x daily
8
10
12
14
16
18
Time
20
22
24
2
4
6
8
16

17. S/C Sliding Scale –still being
practiced
Short acting Insulin S/C 6 or 8 hourly according to
blood sugars
Origin - unknown
Does anyone know how to make
insulin work backwards?
How can you treat the past?
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18. S/C Sliding Scale
Quaele et al 1997
Advantages
Disadvantages
Doctor can
write and
forget it
Unphysiologic
Easy for the
Nurses
Dangerous for Type 1
Does not consider post
meal glucose excursion
More hypos and
hyperglycemias
Roller coaster BS control
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19. Roller coaster blood sugar control while on
sliding scale alone - an example
A patient on Huminsulin30/70 at home
10pm
340
24u Actrapid
6am
72
12pm
356
24u Actrapid
3pm
53
sugar tea given
7pm
102
-
10pm
462
30u plain insulin
2am
35
25%dextrose given
-
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20. Start all patients on Basal Bolus Insulin
Insulin Sensitive:
0.3 U/kg/day
elderly,
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
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Insulin Resistant:
0.75 U/kg/day
Receiving
glucocorticoids
Obesity (BMI >30
kg/m2)
Diabetics receiving
>80 units/day of
insulin
Patients
uncontrolled with
“usual” dose

21. Basal-Bolus regimen
• 25 % Basal - as one NPH at night
• 75 % Bolus - as three premeal short acting or
regular insulin
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22. 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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23. 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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24. 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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25. Insulin Infusion
• Starting Rate:
• Start infusion at a rate – Blood sugar
100
e.g: 346 = 3.46 = 3.5 u/hr
426 = 4.26 = 4.3 u/hr
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26. 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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27. Changing the rate
depends on current infusion rate
•
•
•
•
•
Current Rate
<2 u/hr
2-5 u/hr
5-10 u/hr
> 10 u/hr
Change
0.5u
1u
2u
3u
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28. 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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29. Intraoperative
• Managed by the anesthetist
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30. 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 meal
Do not use the sliding scale
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31. 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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32. 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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33. 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

34. 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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35. 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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36. Transition protocol
To be used when a patient is switched from IV
Insulin Infusion to a SC Regimen
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37. 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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38. 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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39. 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.
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40. 40

41. 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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42. 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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43. 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
43

44. 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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45. Team Endo is always
available for help
Thank you
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