BLOOD GLUCOSE CONTROL

A learning module for Staff

How to Use this Module• Use this module to educate staff on glucose

control.

• Sample slides have been prepared on identifying and managing patients with hyperglycemia.

• You may copy and paste your facility order sets and add your own key points to match your policy and protocols.

Blood Glucose Control

Objectives1. The importance of blood glucose control in

surgical patients.2. Understand the pathophysiology related to

hyperglycemia and safety.3. Educate staff to the policies, procedures, and

protocols.

Why is Blood Glucose Control so Important in the Perioperative Setting?

Hyperglycemia vs No HyperglycemiaAll Patients

02468

10121416

All Pts Bariatric Colectomy

Normal

Gluc>180

All p<0.01

SCOAP data courtesy of Sung (Steve) Kwon

30% of all hyperglycemic patients were not diabetic!

Pathophysiology of Hyperglycemia

GLUCOSE

INCREASED GLUCOSEPRODUCTION

DECREASED INSULIN PRODUCTION

INSULINRESISTANCE

RECEPTOR DEFECT

‘Stress’ Hyperglycemia-What Happens?

• Cytokines/inflammatory mediators contribute to:• Inability of immunoglobulin to bind with surface of invading bacteria so

decreased bacteriocidal capacity.• Impaired platelet function 54% increased blood stream infections

59% increase acute renal failure requiring dialysis and 50% increase in blood transfusions.

• Relative hypoinsulinemia contributes to:• Decreased insulin sensitivity.• Unrestrained free fatty acids and hepatic fatty acids.• Increased ketone bodies and metabolic acidosis.• Impaired myocardial contractility and larger infarct sizes.• Glycosuria induced osmotic diuresis and extracellular K+ shift.

Berghe, 2001; Goldberg & Inzucchi, 2005Adapted from Whitman, 2012 WSHA Webcast

Resulting Complications of Hyperglycemia and Stress Hyperglycemia

Decreased tissue perfusion

Impaired metabolism

Impaired cardiac function

Decreased wound healing

Pro-thrombotic state

Pro-inflammatory state

Braitwaithe, et al. 2008; Adapted from Inzucchi, Magee, & O’Malley, 2010Image retrieved from: http://pennstatehershey.adam.com/content.aspx?productId=42&pid=42&gid=000254Adapted from Whitman, 2012 WSHA Webcast

Physiologic Insulin Secretion: Basal/Bolus Concept

Breakfast Lunch Dinner

Insu

lin(µ

U/m

L)

Glu

cose

(mg/

dL

)

Basal Glucose

150100

50

07 8 9 10 11 12 1 2 3 4 5 6 7 8 9

A.M. P.M.

Time of Day

Basal Insulin

50

25

0

Nutritional Glucose

Nutritional InsulinSuppresses Glucose Production Between Meals & Overnight

The 50/50 Rule

Adapted from Maynard & Wesorick, Society of Hospital Medicine, 2008 J. Whitman, Perioperative Glucose Control, Webcast 2012

Current Best Practices

• Insulin infusion: • If NPO and unstable.

• Basal insulin:• Covers the baseline insulin needs.• Essential for all type 1 diabetics to prevent ketosis.• In most cases should be given even if patient is NPO.

• Nutritional insulin:• Covers increases in serum glucose after caloric intake.

• Correctional insulin:• Additional to scheduled nutritional dose.

Wisse, 2012

Adapted from Whitman, 2012 WSHA Webcast

Oral Hypoglycemic Agents

STOP

Why Not Sliding Scale?

Theoretical glucose levels with SSI

Insulin

Insulin InsulinInsulin

BG (m

g/dL

)

Target range

Adapted from Whitman, 2012 WSHA Webcast

Perioperative Blood Glucose Control

Protocols and Standing Orders

Perioperative Blood Glucose Control ProtocolInsulin Pump Standing OrdersSQ Insulin Standing Orders

Pre-Operative Period

• ALL patients with a blood glucose of 180mg/dl and greater.

• Regardless of diabetes diagnosis or not.

• NOT to be used on OB patients, 23 hour admits or those admitted with DKA or HHS (hyperglycemic crises)

Review the protocol

Intra-operative Glucose Control Period• Measure BG at induction and 1h into case.• Anesthesia associated with hyperglycemia

even in non-diabetic subjects.• Measure BG every 1h in Type 1 DM patients.• Method of glycemic control intra-operatively.• IV insulin (DM1, critically ill, neurosurgery,

TBI).• Basal insulin with bolus correction doses.• Some hospitals have placed glucometers on

every anesthesia cart.Wisse, 2012

• Initiate for BG >140 mg/dL x2 or >180 mg/dL range• Goal range 110-180

mg/dL • Standard infusions

are regular insulin 100ml/100 units on

a dedicated line

Post-Operative Period

• Check BG every hour until at goal

• Then decrease BG checks to every 2 hours

• Hourly checks should always be resumed if patient falls outside of goal range

Post-Operative Period (cont)

Key Steps in Transitioning Off the Insulin Pump• Do know criteria for transitioning off insulin pump• DO overlap SC and IV Insulin. Minimize hyperglycemia because of short ½ life of IV insulin.• DO use rapid analogs (Apidra) after meal if uncertain

patient will eat.• DO expect basal and nutritional insulin if patient is eating.• DO ensure adequate food intake when switching patients

with ketotic diabetes to SC insulin• DO arrange for follow-up post hospitalization even if

insulin is temporary.Carlson, et al., 2006Adapted from Whitman 2012 WSHA Webcast

Suggested Criteria• BG range 90-140 mg/dL .• Stable insulin infusion rate.• Nutrition intake is current or

anticipated.• Need last four hours of insulin

drip data.

Transition Algorithm

• Transition any time of day.• Give basal insulin 2hrs

prior to stopping IV insulin.

• TDD of SC basal insulin = IV units insulin used last 4 hrs x 5.• Also give nutritional

insulin if timing with a meal.

Carlson R. et al. Chest. 2006; Adapted from Wisse, 2012 • Adapted from Whitman 2012 WSHA webcast

Signs and Symptoms of Hypoglycemia

• Sweating • Anxiety • Confusion

• Hunger • Dizziness • Tachycardia

• Irritability • Shakiness • Trembling

• Pallor • Headache • Weakness

Hypoglycemia can occur without symptoms, so it is important to check blood glucose levels regularly.

Adapted from Whitman, 2012 WSHA Webcast

Treating Hypoglycemia: 3 Steps

Give 15g of glucose or Wait 15 mins Recheck BG – give another fast-acting another 15g if carbohydrate necessary • 4oz (1/2 cup) fruit juice * Assess for cause• 8 oz (1 cup) milk• 1 Tbsp honey• IV Dextrose Goal to restore BG above 100 Avoid overtreatment (excessive amount of glucose), which may result in significant hyperglycemia over next 4-6 hrs.

Adapted from Whitman, 2012 WSHA Webcast

PATIENT CARE FLOW SHEET: Blood Glucose Section

The section of this documentation form is appropriate for all nurses to review whether they are on Med/Surg, Telemetry, or Critical Care units.

Documentation of blood glucose control issues include documenting the hyperglycemia and hypoglycemia as well as the treatment. Look closely at this section:

Smooth Transition:Inpatient to Outpatient

• If discharging patient new to insulin:• Make the decision as early as possible.• Teach, teach, teach.• Early follow-up a must.• Pens vs. vial/syringe.

• If changing outpatient regimen significantly:• Communicate with PCP.• Document rationale.• Educate patient.

Wisse, 2012, Adapted from Whitman 2012 WSHA webcast

THE FINISH LINE!!!CONGRATULATIONS!

You have finished the Surgical Glucose Control:

Policies, Procedures, and ProtocolsLearning Module

If you have any questions, please contact your Clinical Educator, your unit’s Diabetes Champion, or one of the Diabetes Educators.