PERIOPERATIVE

BLOOD GLUCOSE
MANAGEMENT
SUNSHINE HEART INSTITUTE
• GOAL

• WHY TO TREAT

• WHOM TO TREAT

• HOW TO IDENTIFY

• HOW TO TREAT

• SAFE GUARDS

• TREATMENT OF COMPLICATIONS

• DISCHARGE PRESCRIPTION
 GOAL

• TARGET BLOOD GLUCOSE 110-180mg/dl.

 WHY TO TREAT

• REDUCE MORTALITY

• REDUCE INCIDENCE OF INFECTIONS

• REDUCE LENGTH OF STAY

• ENHANCE LONG TERM SURVIVAL

 WHOM TO TREAT
• HETEROGENOUS POPULATION WITH HYPERGLYCEMIA

• DIABETICS: Type 1 or Type 2

• PRE DIABETIC

• DENOVO DIABETIC

• STRESS INDUCED HYPERGLYCEMIA

 HOW TO IDENTIFY
• HISTORY:

• Currently on treatment for diabetes.

• Was on treatment for diabetes, but stopped due to

excellent control.

• Herbal, homeopathy, homepathy, ayurveda, unani

and any other alternative treatment.

• Denial of diagnosis and treatment.

• On/Off treatment.
 INVESTIGATIONS
• Known diabetic on treatment

• Check FBS,PPBS and HBA1c

• FBS and PPBS shouldn’t be >25% of normal range

• HBA1c shouldn’t be more than 8gm%. Less than

7.5 is ideal.

• Not a known diabetic

• If random blood sugar is 200 or above at any

point of time, check HBA1c
 HbA1c

• Glycosylated hemoglobin.

• Gives estimate of blood sugar control over

120 days.(Life Span Of RBC)
 Reference blood glucose values

PLASMA
GLUCOSE TEST NORMAL PRE DIABETES DIABETES

200mg/dl or
RANDOM Below 200mg/dl N/A
more
126mg/dl or
FASTING Below 108mg/dl 108-125mg/dl
more

2HR POST 200mg/dl or

Below 140mg/dl 140-199mg/dl
PRANDIAL more
 HbA1c Reference Values

• HbA1c <6.5, with random blood glucose

values of 200mg/dl or above -SIH(Stress
induced hyperglycaemia)

• HbA1c >6.5 - Diabetic.

 Practical issues
(NOT ACCEPTABLE)

• Known diabetic, on prior treatment, with

normal blood sugar: Not given treatment
because sugars are normal

• Not a known diabetic with 200 or above

sugars: Not given treatment because he/she
is not a diabetic.

• Erratic treatment / skipping doses at will.

HOW WE TREAT
 HOW TO TREAT
• Start insulin if not on any treatment.

• HbA1c <7.5 : Continue existing treatment.

• HbA1c 7.5 to 8.5: Continue existing treatment if

sugars are under control.

• Add basal insulin(LANTUS) if sugars are

persistently above 200

• HbA1c >8.5:Stop all oral anti diabetic

medications and start basal, bolus, correctional
insulin regimen.
• Stop Pioglitazone upon admission.

• Stop Metformin 24hrs before surgery.

(Should not receive the day before surgery).

• Add or increase basal insulin(LANTUS)to

cover for stopped medications.
 How much basal insulin
(Lantus) to add?

• Pt on oral anti diabetic agents with sugars

out of range (HbA1c 7.5-8.5)- Calculate
insulin requirement as per standard formula
and start 25-50% of Lantus dose based on
blood sugar values.

• Modify dose next day based on response.

• For a patient whose Metformin is being
stopped the day before surgery, give small
dose of basal insulin(Lantus) the night
before surgery with dinner.(e.g: 2-6 units
based on B.M.I and blood sugar values).
 Avoid

• Adding Metformin to a pre operative patient

who is on Basal, bolus, correctional regimen.

• Adding Metformin in the ICU.

• Generally patients are on combination
medications.

• e.g; Amaryl M1(Glimepiride 1mg and

metformin 500mg)

• The day before surgery, do not give

combination drug.

• Exclude metformin from the combination,

and give the remaining drug in the same
dose, separately.
 If Blood sugars are high the day
before and surgery cannot be cancelled

• Either i.v continuous insulin infusion or

Basal plus bolus subcutaneous insulin
therapy can be used based on availability
and blood sugar levels.

• Avoid short and rapid acting s.c insulin

(Actrapid) in patients on oral anti diabetic
agents currently.
 Correctional Dose Insulin
• To be given along with pre prandial insulin

• If the pre prandial blood sugar is 150 or

above

• In addition to the prescribed dose of

Actrapid

• According to the correctional insulin dosing

chart
Total daily dose of insulin
(T D D)

TOTAL OF 3 DOSES OF ACTRAPID +1DOSE OF LANTUS.

If B.G is less than 70mg/dl and patient has features of
hypoglycaemia:

Do not give insulin.

Follow hypoglycaemia treatment protocol and inform.

If B.G is less than 70 and patient has no features of hypoglycaemia:
Give food which is due, and give reduced dose of insulin if it is high.
 Post op
• Shift to subcutaneous insulin once the patient
starts eating about 50% of normal diet.

• First dose of Lantus can be given with lunch

and next day dose shifted to after dinner.

• Do not start/prescribe Metformin in the ICU

• Add Metformin if the Insulin dose is near 1unit/

kg/day and sugars are not controlled and
patient is eating at least 50% of normal diet.
 SAFEGUARDS

• Meal should be present in the room/ICU

before giving insulin.
INSULIN SYRINGE
Insulin is measured in units
Always use insulin syringe of 40U/ml type.
 Items to be available on the
floor/ward at all times
• Glucometer with strips and lancet

• Glucose/Sugar

• 25% Dextrose, 100ml

• I.V cannula (18/20G)

• Syringe 20ml.
TREATMENT OF
COMPLICATIONS
HYPOGLYCEMIA
 Discharge prescription
• 1.Subcutaneous insulin in the prescribed
format

• 2.If any oral diabetic agents are added for post

operative patients, they too should be
prescribed, after confirming with primary
consultant (C.t surgeon).

• 3.Chart containing symptoms of hypoglycaemia

and treatment should be given to the patient
and explained in their vernacular language.