Post op hyperglycemia

[CaliDreamin4Life]

What's your go to insulin and mode of administration for reducing post op hyperglycemia...how do you approach your patients who have this, eg not chasing after blood sugars but treating if you think they are presently uncontrolled ? Any evidence for how to treat and when?

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[Chloroform4Life]

No evidence for this population.

For ICU, cardiac, and maybe neuro patients, keeping BG less than 180 in periop period is recommended. Perhaps keeping all patient's BG less than 180 is a reasonable goal as well.

I give IV regular insulin, about 1 unit for every 10-20 points above 180. More if patient is insulin resistant and is on a lot of baseline insulin.

 

[fakin' the funk]

Goal < 180-200 for most types of cases.

The less acute/major the case, the less I care (bc it matters less).

Regular IV insulin bolus and drip usually is the way to go. Find your hospital's protocol for initiating IV insulin drips. In the ballpark of 0.1 unit/kg bolus then 0.1 unit/kg/hr, but it depends on how high above your target you are. If you bolus, I think you buy yourself at least 2 q30min glucose checks before going to q1hr.

In a very long, very stable case you could make an argument for subcutaneous regular insulin.

Please do not give Lispro to patients who are not eating.

 

[CaliDreamin4Life]

Thanks guys

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[turnupthevapor]

Goal < 180-200 for most types of cases.

The less acute/major the case, the less I care (bc it matters less).

Regular IV insulin bolus and drip usually is the way to go. Find your hospital's protocol for initiating IV insulin drips. In the ballpark of 0.1 unit/kg bolus then 0.1 unit/kg/hr, but it depends on how high above your target you are. If you bolus, I think you buy yourself at least 2 q30min glucose checks before going to q1hr.

In a very long, very stable case you could make an argument for subcutaneous regular insulin.

Please do not give Lispro to patients who are not eating.

Why not lispro?

 

[Chloroform4Life]

Why not lispro?

Lispro has a short duration of action with quick onset, which is great for that postprandial glucose load. Not so great for treating baseline hyperglycemia in an npo patient. Also, it can't be given IV.

 

[Urzuz]

Regular IV insulin bolus and drip usually is the way to go. Find your hospital's protocol for initiating IV insulin drips. In the ballpark of 0.1 unit/kg bolus then 0.1 unit/kg/hr, but it depends on how high above your target you are. If you bolus, I think you buy yourself at least 2 q30min glucose checks before going to q1hr.

Not sure if you're talking IBW or TBW, but giving 0.1 units/kg * TBW of regular insulin may make some patients hypoglycemic unless their glucose is through the roof or they are super insulin resistant (I know you said it depends on how high above target you are, but I don't think I've ever pushed 0.1 units/kg in the OR). The way I view it, having good glucose control is usually more of a longer term problem than I manage patients for, and the risks of hypoglycemia in the short term (in the OR) outweigh the risks of hyperglycemia...so I usually start out a little more conservative than that. Also keep in mind that patients aren't inputting any glucose into their system while they are with us...unless you start them on some dextrose.

Agree with the rest of your post though.

 

[Chloroform4Life]

Not sure if you're talking IBW or TBW, but giving 0.1 units/kg * TBW of regular insulin may make some patients hypoglycemic unless their glucose is through the roof or they are super insulin resistant (I know you said it depends on how high above target you are, but I don't think I've ever pushed 0.1 units/kg in the OR). The way I view it, having good glucose control is usually more of a longer term problem than I manage patients for, and the risks of hypoglycemia in the short term (in the OR) outweigh the risks of hyperglycemia...so I usually start out a little more conservative than that. Also keep in mind that patients aren't inputting any glucose into their system while they are with us...unless you start them on some dextrose.

Agree with the rest of your post though.

I agree with avoiding hypoglycemia as well. However, I also don't think we do a good enough job controlling patients glucose most of the time. I think a lot of that has to do with the fact that we don't pay much attention to complications beyond the immediate postoperative period. Our patients could be developing wound infection or poor wound healing 1-2 weeks post-op and we wouldn't know about it.

0.1 unit/kg isn't really that much in some folks. For a 100kg patient, that's just 10 units. How often have you had a fasting patient come in with a glucose of 300, give 6 units insulin, and the repeat glucose is 250? I've seen quite a few of those... they are usually the ones on 60 units Lantus who are told to not take it the night before surgery.

 

[VanDiemen]

Lispro has a short duration of action with quick onset, which is great for that postprandial glucose load. Not so great for treating baseline hyperglycemia in an npo patient. Also, it can't be given IV.

Why is 'short duration of action with quick onset' not great for titrating glucose in an npo patient? I would say the exact opposite is true. IV regular insulin has an even shorter duration of action with an even quicker onset.

 

[Urzuz]

I agree with avoiding hypoglycemia as well. However, I also don't think we do a good enough job controlling patients glucose most of the time. I think a lot of that has to do with the fact that we don't pay much attention to complications beyond the immediate postoperative period. Our patients could be developing wound infection or poor wound healing 1-2 weeks post-op and we wouldn't know about it.

0.1 unit/kg isn't really that much in some folks. For a 100kg patient, that's just 10 units. How often have you had a fasting patient come in with a glucose of 300, give 6 units insulin, and the repeat glucose is 250? I've seen quite a few of those... they are usually the ones on 60 units Lantus who are told to not take it the night before surgery.

Agreed, I do see that from time to time. But I have also see patients with a BS of 350 drop to 180 after 4 units of insulin.

As the old anesthesia saying goes, you can always give more, but you can't take away what has already been given!

I agree that having poor glucose control is a big problem, and it should be managed appropriately when you encounter such situations. However, my thinking is that the risk of having a patient's blood sugar at less-than-ideal for two extra hours during the surgery until I titrate in enough insulin is less than the risk of bolusing 10 units, potentially having them end up with a blood sugar of 60, and then battling the hypoglycemia thereafter. Different ways of approaching the same problem.

Edit: Also, forgot to mention...I usually use the first bolus of insulin to judge for myself how insulin sensitive/resistant they actually are. Based on what they do with that first dose, I will recheck and give another dose in an hour if needed.

 

[fakin' the funk]

Why is 'short duration of action with quick onset' not great for titrating glucose in an npo patient? I would say the exact opposite is true. IV regular insulin has an even shorter duration of action with an even quicker onset.

Because glucose homeostasis isn't like pain or surgical stimulus (changing profoundly minute to minute).

It is also wrong to just push IV regular insulin x 1 and expect your hyperglycemia problem to be solved.

 

[cchoukal]

My favorite way to treat post-op hyperglycemia is not to do elective surgery on people who are poorly controlled. Ha, right! It's supremely frustrating that the patient, the pmd, and the surgeon couldn't be bothered to solve this issue before scheduling the case, particularly in light of the known complications of poorly controlled diabetes, and then weveryone feels like we have to do something for the one hour they're in PACU or th sky is going to fall. My take is that the data on glycemic control in the or and icu are not particularly compelling and I'd rather send someone home too high than sit on a hypoglycemic patient for a few hours in PACU because I tried to fix something that didn't matter. My favorite are the eye patients who come in at 290 (my cut-off is 300) and the surgeons want to do the case, but when they're 301 after the case, they freak out about sending the guy home.

 

[VanDiemen]

Because glucose homeostasis isn't like pain or surgical stimulus (changing profoundly minute to minute).

It is also wrong to just push IV regular insulin x 1 and expect your hyperglycemia problem to be solved.

I think I may be misunderstanding. My assumption was that the ideal pharmacokinetics in this situation are ultrashort duration and onset, since that is the only way to get precise balance between glucose production and disposal. So the problem with lispro is that the onset and duration aren't short ENOUGH, not that they are short.
Also glucose can change profoundly in minutes, glucose production can triple in a matter of minutes from epinephrine.