Insulin while NPO?

1. 0 Silly question: would you give insulin to a patient who was NPO before surgery? It seems like the answer could be obvious, but I am feeling a little guilty. Scenario: Mr. Smith was an elderly, diabetic patient admitted at 3am for SBO on a busy night shift. BG in ER initially was 130. I wake up the groggy resident to call for admit orders, and I forget to remind her the patient is diabetic. She states he should be kept NPO for surgery in the AM. About an hour later, I realize I didn't get an order for BG AC&HS or a sliding scale. I grab a blood sugar, and it is 185. I ask my charge nurse if I should wake the resident up again for a sliding scale order, and she states he is NPO and the blood sugar wasn't that high, so I wouldn't be covering regardless. I was hoping the resident would be in early so I could still ask before I left, but they weren't so I ended up passing it on to dayshift. I feel bad now for not covering the patient.

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2. 12 Comments

   Comment
3. 
   #1 2

   Apr 1, '12 by Do-over, ASN, RN

   Like so many things... it depends.
   
   It would up to the physician, really. They can't be too high going into surgery, and more than food affects blood glucose. Usually, if I have an NPO patient with a 0700 BS that would normally be covered I just call the doc and see what they want.
4. 
   #2 0

   Apr 4, '12 by turnforthenurse, BSN

   Yup, it depends. Our diabetic educators tell us to not hold their sliding scale (correctional) insulin, but hold their pre-prandial insulin. But again, this should be clarified with the doc. Some will tell you to hold insulin while others will tell you to give it.
5. 
   #3 0

   Apr 4, '12 by rn/writer

   Basal insulins are usually not withheld because they give 24-hour coverage. But other insulins have different actions and really should be addressed by a protocol, standing orders, ot patient-specific orders.

   Last edit by rn/writer on Apr 4, '12
6. 
   #4 1

   Apr 4, '12 by Rose_Queen, MSN, RN Guide

   You really should check with the doc. We've had some patients come down to surgery without having gotten any insulin for the last 16 hours- even though their AM blood glucose was over 300. Add in the stress of surgery, and then we're really fighting to get that glucose below our target of 150. Makes me wonder just how many surgical infections/complications could have been avoided if the blood sugar had been under control before surgery.
7. 
   #5 1

   Apr 5, '12 by turnforthenurse, BSN

   Quote from rn/writer

   Basal insulins are usually not withheld because they give 24-hour coverage. But other insulins have different actions and really should be addressed by a protocol, standing orders, ot patient-specific orders.

   But based on the blood sugar, the basal insulin dose may need to be adjusted. The patient may not need all 50 units of Levemir if their blood sugar is 90. Call the doctor and ask and see if they will prescribe a reduced dose. This is another thing our diabetic educators tell us.
8. 
   #6 4

   Apr 5, '12 by rn/writer

   Quote from turnforthenurseRN

   But based on the blood sugar, the basal insulin dose may need to be adjusted. The patient may not need all 50 units of Levemir if their blood sugar is 90. Call the doctor and ask and see if they will prescribe a reduced dose. This is another thing our diabetic educators tell us.

   Blood sugar may also determine whether the patient is given NS, LR or D5W in his/her IV.
   
   The unfortunate thing is that a lot of surgeons get skittish when dealing with diabetic patients. It's good when there are established protocols or a hospitalist or the primary care doc is involved and can manage the medical aspect of the patient's care while the surgeon concentrates on his or her area of expertise.
9. 
   #7 0

   Apr 8, '12 by Vespertinas

   Quote from rn/writer

   Basal insulins are usually not withheld because they give 24-hour coverage. But other insulins have different actions and really should be addressed by a protocol, standing orders, ot patient-specific orders.

   Adding to the chorus of "it depends" I'd like to mention that my last facility had us give half the basal dose for next day ORs
10. 
    #8 0

    Apr 9, '12 by BluegrassRN

    Passing it on to the day shift would have been perfectly acceptable in my facility. We want our blood sugars to be between 140-180, according to our order sets. 185 isn't that far off. AM/preop labs will show her blood glucose, and if the doc wants to address it prior to surgery, he can.
11. 
    #9 1

    Apr 9, '12 by classicdame

    you did not mention the type of insulin, although anything given on a sliding scale would probably rate a "no" to your question.
    
    Basal insulin should not be stopped, even if patient is NPO (Lantus, Levimir and sometimes NPH if MD orders). The body needs insulin 24/7. THe stress of surgery will make BS rise.
    
    If a procedure is of short duration, and glucose checks are frequent enough, addtional insulin may be ordered. Again, it would be the MD's discretion. It is not impossible for glucose or dextrose to be given IV during a procedure, but it is an "extra" thing to be monitored, so MD's much prefer the patient be in good control prior to the surgery.
12. 
    #10 0

    Apr 13, '12 by Anna Flaxis, ASN

    I think your charge nurse was correct. When I worked the floor, our sliding scale protocol only covered HS CBGs >200 (or was it 250?). An HS CBG of 185 would not have received a sliding scale dose.
    
    Long acting insulin such as Lantus would be a bit different, since they are supposed to be peakless. If the patient is receiving dextrose containing fluids, then the admitting doc might want them to get their long acting insulin.
    
    The patient will most likely be coming out of surgery with some sort of IV insulin protocol in place until they are taking P.O.
    
    In conclusion, I wouldn't worry myself over an HS CBG of 185 on an NPO pre-op patient.
13. 
    #11 2

    Apr 15, '12 by kkit

    I agree that it is always safest to ask the physician in situations were the patient is NPO for surgery and has a high BS. HOWEVER, 185 is not worth waking the doctor up. You did the right thing. If the BS was > 200 I would have called, though.
14. 
    #12 0

    Apr 21, '12 by JGmomof2

    I agree, doc has final word. Be your patients advocate though and request that at least partial dose of BASAL is given, maybe even give the whole dose depending on procedure time, insulin resistance,past blood sugars following NPO status. After all, their bodies are not making enough of it, they need their insulin!
    Obviously hold pre-prandial dose since they are NPO.
    Personally, I would give the sliding scale coverage as well. If you're NPO and your BG is greater than 250-your patients body will suffer high or low, and a stble bg prior to a procedure is a must!

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