What is your threshold for treating an elevated blood glucose?

[jd1572]

Suppose you check a finger stick glucose of a diabetic patient prior to surgery, and it's high. Otherwise patient is asymptomatic and in no acute distress. Some questions:

1. What is your threshold for treating the high glucose with insulin?
I've read in one book that a number >250 should be treated with insulin, but it seems arbitrary. They mention decreased PMN function with a glucose >250. Anyone have any studies to back up their opinion?

2. Is there a glucose level that is high enough that you would cancel the case? (Again, assuming patient otherwise OK)
Again, anyone know of any literature to support their reasoning?

3. What about thresholds for treating glucose intra-op? I'm a little bit fuzzy on the current studies, but my understanding is that the cardiac surgery literature showed benefits to tight intra-op glucose control.

Thanks!

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[periopdoc]

Ever since the NICE Sugar Study came out and confirmed my suspicion of and bias against tight glucose control, I simply aim to keep blood glucose under 180 unless some orthopedist points to the wall and says, "the chart on the wall says that we start insulin when the glucose exceeds 115. I am from a non-cognitive specialty and until the chart says something different we will start insulin on ALL of my patients who exceed that level. End of discussion.". He got one thing right.

I am more liberal with insulin in my bypass patients although I am not yet entirely convinced that tight glucose control is optimal even on these patients.

Most of the data comes from ICU patients and I am leery about applying that data to the patient undergoing acute intraoperative stress, especially the general, non-cardiac surgery population.

Hopefully NICE Sugar will stimulate more interest in real, controlled outcomes studies of tight intraoperative control, but until then we really don't know what kind of control is optimal. We just have to aim for reasonable and remain vigilant, especially if aiming for "tight" glucose control.

Do a search on cancelling cases based on isolated elevated glucose. We had a long, good, and fairly acrimonious discussion on this recently that doesn't bear repeating.

-pod

 

[coprolalia]

... unless some orthopedist points to the wall and says, "the chart on the wall says that we start insulin when the glucose exceeds 115. I am from a non-cognitive specialty and until the chart says something different we will start insulin on ALL of my patients who exceed that level. End of discussion.". He got one thing right.

-copro

 

[dhb]

1. What is your threshold for treating the high glucose with insulin?

It depends on the patient: how well his diabetes is controlled is he on insuline (what kind): if very well controlled i would start insulin if his BG is over 150, if poorly controlled i would not try at all cost to get it normalized but i would aim for a value < 200mg/dl .

 

[jd1572]

Thanks for bringing up the NICE-Sugar Study! When I have been giving insulin to diabetic patients intra-op or pre-op, my main goal is to just give a little so it does not go too crazy high. I've never actually tried to have a goal of normalizing it. Just wondering what everyone else is doing.

 

[coprolalia]

Thanks for bringing up the NICE-Sugar Study! When I have been giving insulin to diabetic patients intra-op or pre-op, my main goal is to just give a little so it does not go too crazy high. I've never actually tried to have a goal of normalizing it. Just wondering what everyone else is doing.

Yeah, if your goal is to go all "Internal Medicine" in the OR, you better be ready to go all the way (replete K+, etc.).

-copro

 

[Bertelman]

Thanks for bringing up the NICE-Sugar Study! When I have been giving insulin to diabetic patients intra-op or pre-op, my main goal is to just give a little so it does not go too crazy high. I've never actually tried to have a goal of normalizing it. Just wondering what everyone else is doing.

I do just enough so that the PACU nurses don't give me the stinkeye when I tell them I didn't check my diabetic patient's glc in the OR. My rough cutoff is 180. Below that, I don't go crazy. Above, I'll give 5 or 10 of insulin. Some may call that crazy.