Peri-Operative Management of Adult Diabetes Procedure

Transcription

1 All staff using the Fluid & Medication Management policies must first familiarise themselves with the contents of: Roles & Responsibilities Policy Basic Infection Prevention & Control Principles related to Fluid & Medication Patient Identification Policy 1. Purpose The aim of this protocol for perioperative management of diabetes mellitus is to avoid hypoglycaemia, excessive hyperglycaemia (>12mmol/L), prevent protein catabolism, lipolysis and electrolyte disorders while the patient is fasting. Scope Nurse/Midwife Level 1 IV (Intravenous) Certificated Nurse/Midwife (for IV administration) RMO Associated Documents Adult Perioperative Insulin/Plasma-Lyte % Glucose Infusion form. Information Normal capillary blood Glucose is mmol/L. There are three groups of adult diabetic patients: Type 1 Diabetes Type 2 Diabetes requiring Insulin Type 2 Diabetes not requiring Insulin Perioperative diabetes management depends on the type of anaesthetic and whether the surgery is minor or major. 2. Type of Anaesthetic Local anaesthesia without sedation Surgery performed with local anaesthetic infiltration only, e.g. plastic surgery procedures. These patients are not routinely made nil by mouth, they should have their usual food and medications on the day of surgery. Local anaesthesia with sedation / regional anaesthesia / general anaesthesia Regional anaesthesia includes arm blocks and spinal anaesthesia. These patients need to be nil by mouth and should be managed according to the guidelines below. If in doubt, patients should be kept nil by mouth. The exact management plan will be determined by the Anaesthetist and surgical team. Peri-Operative Management of Adult Diabetes Page 1 of 9

2 3. Surgery Minor The patient is expected to resume normal oral intake on the day of surgery See post operative management section below Major The patient is expected to resume oral intake on the day after surgery or later See post operative management section below 4. Type 1 Diabetes Mellitus Peri-Operative Diabetic Management 4.1 Type I Diabetes Mellitus (ABSOLUTE deficiency) Minor Surgery Morning Surgery - Minor (Blood Glucose Level) Omit morning Insulin Monitor BGL every 2 hours Consult medical staff if BGL <4mmol/L or > 12 mmol/l Afternoon Surgery - Minor Administer half the morning dose of Insulin Give a light breakfast before 0730hrs Monitor BGL every 2 hours Consult medical staff if BGL <4mmol/L or > 12 mmol/l If above 12 mmol/l consider commencement of the Insulin/Plasma-Lyte % Glucose Infusion as per prescription 4.2 Type I Diabetes Mellitus (ABSOLUTE deficiency) Major Surgery Morning Surgery - Major Omit morning Insulin Monitor BGL every 2 hours and adjust rate according to prescription Peri-Operative Management of Adult Diabetes Page 2 of 9

3 Afternoon Surgery - Major Administer half the morning Insulin Give a light breakfast before 0730hrs Monitor BGL every 2 hours and adjust rate according to prescription 5. Type 2 Diabetes Mellitus Requiring INSULIN Peri-Operative Diabetic Management 5.1 Type 2 Diabetes Mellitus requiring INSULIN MINOR Surgery These patients often have some residual Insulin secretion and are less prone to ketoacidosis Morning Surgery - Minor Document baseline BGL Omit morning Insulin and oral hypoglycaemic on day of surgery Monitor BGL every 2 hours Consult medical staff if BGL <4mmol/L or > 12 mmol/l If above 12 mmol/l consult medical staff to consider commencement of the Insulin/Plasma-Lyte % Glucose Infusion as per prescription Afternoon Surgery - Minor Omit morning and lunchtime oral hypoglycaemias on day of surgery Administer half of morning dose of Insulin Give a light breakfast before 0730hrs Monitor BGL every 2 hours Consult medical staff if BGL <4mmol/L or > 12 mmol/l If above 12 mmol/l consult medical staff to consider commencement of the Insulin/Plasma-Lyte % Glucose Infusion as per prescription 5.2 Type 2 Diabetes Mellitus requiring INSULIN MAJOR Surgery Morning Surgery - Major Document baseline BGL on admission Omit morning Insulin and morning and afternoon oral hypoglycaemics on day of surgery Peri-Operative Management of Adult Diabetes Page 3 of 9

4 Monitor BGL every 2 hours and adjust rate according to prescription Afternoon Surgery - Major Document baseline BGL on admission Administer half of morning Insulin Omit oral hypoglycaemics on day of surgery Give a light breakfast before 0730hrs Monitor BGL every 2 hours and adjust rate according to prescription 6. Type 2 Diabetes Mellitus NOT Requiring INSULIN Peri-Operative Diabetic Management 6.1 Type 2 Diabetes Mellitus NOT requiring INSULIN MINOR Surgery Morning Surgery - Minor Omit oral hypoglycaemic on day of surgery Monitor BGL every 4 hours Consult medical staff if BGL <4mmol/L or > 12mmol/L If below 4 mmol/l notify medical staff, commence Plasma-Lyte % Glucose Infusion as per prescription, and monitor BGL every 2 hours If > 12 mmol/l consult medical staff to consider commencement of Insulin/Plasma-Lyte % Glucose Infusion as per prescription Afternoon Surgery - Minor Omit oral hypoglycaemic on day of surgery Monitor BGL every 4 hours Consult medical staff if BGL <4mmol/L or > 12mmol/L If below 4 mmol/l commence Plasma-Lyte % Glucose Infusion as per prescription, and monitor BGL hourly If > 12 mmol/l consult medical staff to consider commencement of Insulin/Plasma-Lyte % Glucose Infusion as per prescription Peri-Operative Management of Adult Diabetes Page 4 of 9

5 6.2 Type 2 Diabetes Mellitus NOT requiring INSULIN MAJOR Surgery Morning Surgery - Major Omit oral hypoglycaemic on day of surgery Monitor BGL 2 hourly and adjust rate according to Insulin/Plasma-Lyte % Glucose Infusion as per prescription Consult medical staff if BGL <4mmol/L or > 12mmol/L Afternoon Surgery - Major Omit oral hypoglycaemic on day of surgery Commence Insulin/Plasma-Lyte % Glucose Infusion as per prescription Monitor BGL 2 hourly and adjust rate according to Insulin/Plasma-Lyte % Glucose Infusion as per prescription Consult medical staff if BGL <4mmol/L or > 12mmol/L 7. Post Operative Management of Diabetes Mellitus 7.1 Minor Surgery Post Operative Management Type 1 Diabetes Mellitus requiring INSULIN Once eating, administer subcutaneous Insulin Stop Insulin/Plasma-Lyte % Glucose Infusion two hours after administration of subcutaneous Insulin Resume normal diabetic regime in discussion with patient Restart glargine (Lantus) on evening of day of surgery Type 2 Diabetes Mellitus requiring INSULIN Once eating, administer subcutaneous Insulin Stop Insulin/Plasma-Lyte % Glucose Infusion two hours after administration of subcutaneous Insulin Resume normal diabetic regime in discussion with patient Restart glargine (Lantus) on evening of day of surgery Peri-Operative Management of Adult Diabetes Page 5 of 9

6 Type 2 Diabetes Mellitus NOT requiring INSULIN Once eating give oral hypoglycaemic If used, stop Insulin/Plasma-Lyte % Glucose Infusion two hours after oral hypoglycaemic Resume normal diabetic regime in discussion with patient 7.2 Major Surgery Post Operative Management Type 1 Diabetes Mellitus requiring INSULIN If a patient is usually on glargine (Lantus), aim to restart early Discuss the transition from the Insulin/Plasma-Lyte % Glucose Infusion to subcutaneous Insulin with the RMO/Consultant Patients on prolonged Insulin Infusions need plasma sodium and potassium levels monitored, as they may become hyponatraemic and/or hypokalaemic The Insulin/Plasma-Lyte % Glucose Infusion is only intended for use over a 24 hour period Type 2 Diabetes Mellitus requiring INSULIN If a patient is usually on glargine (Lantus), aim to restart early Discuss the transition from the Insulin/Plasma-Lyte % Glucose Infusion to subcutaneous Insulin with the RMO/Consultant Patients on prolonged Insulin Infusions need plasma Sodium and Potassium levels monitored, as they may become hyponatraemic and/or hypokalaemic The Insulin/Plasma-Lyte % Glucose Infusion is only intended for use over a 24 hour period If patient usually on an oral hypoglycaemic - restart when patient resumes normal diet Type 2 Diabetes Mellitus NOT requiring INSULIN If used, stop Insulin/Plasma-Lyte % Glucose Infusion when they resume normal diet Restart oral hypoglycaemic when patient resumes normal diet Resume normal diabetic regime in discussion with patient Revision History Version: 1 Developed by: Anaesthetist Pharmacist CNE (Adapted from CDHB document ref: 4732) Authorised by: CQIT Date Authorised: April 2015 (TBC) Date last reviewed: Date of next review: April 2017 Peri-Operative Management of Adult Diabetes Page 6 of 9

7 Adult Perioperative Insulin/Plasma-Lyte % Glucose Infusion A standardised Insulin/Plasma-Lyte % Glucose Infusion for the perioperative management of adult diabetes mellitus. 1. Omit subcutaneous insulin and/or oral hypoglycaemic on the day of surgery 2. Is the patient (please tick) Type 1 Diabetes Type 2 Diabetes requiring Insulin Type 2 Diabetes NOT on Insulin 3. Measure blood glucose level (BGL) and record on the reverse of this form and establish intravenous access. 4. Prepare Plasma-Lyte % Glucose Infusion Take 1000mL bag of Plasma-Lyte 148 Replacement and 5% Glucose and prime volumetric giving set. Connect to patient and run at 100mL per hour (or prescribed rate). 5. Prepare Actrapid Insulin Infusion. (Use a luer lock 60mL syringe) In a syringe add 50 units of Actrapid Insulin to Sodium Chloride 0.9% to make up to 50mL (1unit/mL) Attach medication additive label Connect a microbore Infusion set to syringe and prime the line Load syringe into syringe driver and select Insulin Infusion rate as per scale below and measured BGL Connect syringe Infusion set to the distal port (one nearest the patient) of the Plasma-Lyte 148 Infusion + 5% Glucose 6. The two Infusions must be established together 7. Check BGL and any Infusion rate change on the reverse of this form Prescribe insulin rate as follows: < 3.0 mmol/l Stop Insulin Infusion, call medical staff mmol/l If Type 1 Diabetes Run at 0.5 ml/hr (0.5 unit/hour); however, if symptomatic, stop Insulin Infusion only, check BGL every 15 minutes and recommence Insulin Infusion at 0.5 ml/hr (0.5 unit/hour) when BGL is 3.5 mmol/l or higher. If Type 2 Diabetes Stop Insulin Infusion and contact medical staff. Peri-Operative Management of Adult Diabetes Page 7 of 9

8 mmol/l Run at 0.5 ml/hr (0.5 unit/hour) mmol/l Run at 1mL/hr (1 unit/hour) mmol/l Run at 1.5 ml/hr (1.5 units/hour) > 15 mmol/l Contact medical staff Anaesthetist: Date: Time: Insulin resistant patients (normally on >100 units/day or having marked central adiposity) may require doubling of the above Insulin rates. Peri-Operative Management of Adult Diabetes Page 8 of 9

9 Patient Label Adult Perioperative Insulin/Glucose Infusion Date Time Infusion Plasma-Lyte 148 with 5% Glucose (1000mL) 50 units Actrapid in Sodium Chloride 0.9% to make 50mL syringe Nurse 1 Signature Nurse 2 Signature Time Blood Glucose Level Insulin Infusion Rate Nurse 1 Signature Nurse 2 Signature Check blood glucose two hourly and alter the Insulin Infusion accordingly: a) If there is no alteration of Insulin rate after four consecutive blood glucose recordings and the patient is clinically stable, then measure BGL four hourly. b) If there is a change in Insulin Infusion rate, recommence two hourly BGL monitoring. c) If there is any alteration of patient's clinical state, recheck BGL immediately. d) Rechart and review Insulin/Plasma-Lyte % Glucose Infusion every 24 hours hyponatraemia and water retention may become a problem. Consider changing to 10% Glucose at 50mL/hr. e) Patients on Insulin/Plasma-Lyte % Glucose Infusion are prone to hypokalaemia Medical Officers check Potassium levels every 12 hours until eating is established. Peri-Operative Management of Adult Diabetes Page 9 of 9