Hyperglycemia In PACU

[Beeftenderloin]

How are people managing hyperglycemia in PACU.

A lot (Obviously not all) of the attendings I work with are very hesitant to give insulin to patients that are hyperglycemic post-op and usually either just discharge them and tell them to resume home medications for outpatients or just let primary team manage it once the patient leaves PACU and gets to the floor.

Just wondering how people at other institutions are approaching this: insulin-naive/not naive, blood sugar cut-offs, treatment modalities (insulin type/quantity) etc.

thanks.

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[deleted875186]

Other than preventing complications from very high sugars, I think the risks outweigh the benefits from treating sugars in the PACU. They will need blood sugar control postop on te floor. I personally try to never give insulin to an insulin naive patient postop if they are going home. I’m fine tearing an insulin non naive patient in the PACU, just ask them their total daily dose to get an idea of how resistant they are.

 

[deleted697535]

If it's post cardiac then you gotta be all over that. Iv infusion all round.

Not great evidence to go nuts over non post cardiac hyperglycemia. I'd probably aim for < 12 with a couple Sc units of novo rapid but don't go overboard. Hypoglycemia way worse.

Bad news is there are 3 international guides on periop dm mgt. 1 UK 2015, 1 us 2010 approx and 1 Australian 2012 I think. None are great or fully agree. And the field has evolved so much since. The incretins are amazing drugs.

A bigger q to ask is what antihyperglyceimcs are they on? What procedure they had? Risk of infx? There is lowish evidence that dpp4i and glp1 agonist can safely be continued periop. Metformin also

 

[deleted875186]

If it's post cardiac then you gotta be all over that. Iv infusion all round.

Not great evidence to go nuts over non post cardiac hyperglycemia. I'd probably aim for < 12 with a couple Sc units of novo rapid but don't go overboard. Hypoglycemia way worse.

Bad news is there are 3 international guides on periop dm mgt. 1 UK 2015, 1 us 2010 approx and 1 Australian 2012 I think. None are great or fully agree. And the field has evolved so much since. The incretins are amazing drugs.

A bigger q to ask is what antihyperglyceimcs are they on? What procedure they had? Risk of infx? There is lowish evidence that dpp4i and glp1 agonist can safely be continued periop. Metformin also

Agreed. I would say I’m much more aggressive for patients that will be going to he ICU, post cardiac, ICU patients, critically ill, all these patients will get monitored enough to be aggressive. Agree that the insulin infusion is easiest, but i feel more comfortable bolusin IV insulin to get rapid control.

 

[MoMoGesiologist]

If glucose >200, give some sq insulin per the insulin sensitive table in your EMR just to say you did something (for outpatients and floor pts) and keep it moving. Agree with above poster that sick pts and big surgeries need insulin drip

 

[fakin' the funk]

My center has a widespread and robust periop normoglycemia protocol, aimed at identifying undiagnosed diabetics preop and normalizing BG perioperatively.

Everyone gets a FSBG preop (drop of blood off the angiocath when preop nurse starts the IV). Inpatients and diabetics get FSBG post-op.

SC lispro q4h is the drug of choice - we have low, medium, and high intensity sliding scales. Goal is 80-200.

Please do not give IV insulin and think you did anything - it lasts like 15 minutes. (Unless you're treating hyperkalemia)

 

[deleted171991]

My center has a widespread and robust periop normoglycemia protocol, aimed at identifying undiagnosed diabetics preop and normalizing BG perioperatively.

Everyone gets a FSBG preop (drop of blood off the angiocath when preop nurse starts the IV). Inpatients and diabetics get FSBG post-op.

SC lispro q4h is the drug of choice - we have low, medium, and high intensity sliding scales. Goal is 80-200.

Please do not give IV insulin and think you did anything - it lasts like 15 minutes. (Unless you're treating hyperkalemia)

IV regular insulin lasts about an hour (4 half-lives), but still not much.