Postoperative Management of Diabetes Mellitus: Steady-State Glucose Control With Bedside Algorithm for Insulin Adjustment

Abstract

An algorithm was developed to determine whether an individualized insulin infusion could maintain plasma glucose in a desirable steady state after surgery. In 24 patients, insulin was provided according to a "glucose-feedback" formula to maintain plasma glucose between 120 and 180 mg/dl (6.7-10.0 mM). Initial plasma glucose was elevated, 218 +/- 16 mg/dl (mean +/- SE 12.1 +/- 0.9 mM), but reached the target range after 8 h and remained steady for the rest of the study period. Insulin requirements varied considerably, 0.5-5.0 U/h. Infusion rates were correlated with initial plasma glucose but not with previous insulin dose, HbA1c, or percent ideal body weight. Although insulin needs cannot be predicted, plasma glucose can be maintained in a desirable range after surgery via a simple formula suitable for implementation by general ward nurses.

Management of Diabetes and Hyperglycemia in Hospitals

“…Many institutions use insulin infusion algorithms that can be implemented by nursing staff (2,189,194,197,200,280,298,301,304,307,314). Algorithms should incorporate the concept that maintenance requirements differ between patients and change over the course of treatment.…”

Designing and implementing insulin infusion protocols and order sets

“…These early publications featured algorithms that adjusted insulin infusions solely on the basis of glucose level, and did not take the velocity of change, direction of change, proximity to glycemic target, or different insulin sensitivities into account. Also, the targeted glucose goals in those reports were not consistent with the present standards 29–31. Other published protocols featured glucose‐insulin‐potassium infusion (GIK) protocols that focused on the amount of insulin administered and failed to attain appropriately defined glucose targets 32, 33.…”

Blood glucose management in the patient undergoing cardiac surgery: A review

“…neutral protamine hagedorn insulin (and other wound healing and increased rates of infection [51,52] . The implications that this would have on diabetic patients undergoing surgery were clear, and by the late 1980s, algorithms for postoperative insulin infusions were widely available [53] . In 1987, Watts et al [53] advocated a target plasma glucose range of 120 to 180 mg/dL (6.7 to 10.0 mmol/L) at a time when ideal blood glucose ranges were not well established.…”

“…The implications that this would have on diabetic patients undergoing surgery were clear, and by the late 1980s, algorithms for postoperative insulin infusions were widely available [53] . In 1987, Watts et al [53] advocated a target plasma glucose range of 120 to 180 mg/dL (6.7 to 10.0 mmol/L) at a time when ideal blood glucose ranges were not well established. As a result of the lack of consensus on so many issues related to diabetic management, there was marked variation in accepted clinical practice.…”