treatment of post-op hyperglycemia

  1. I'm interested in how post-op hyperglycemia is being managed. Of particular interest are cardiac surgery patients. Are you using insulin drips, sliding scales, or both? Any protocols you can clue me into? At what level of blood glucose are you starting to treat? Also, does anyone have any articles that relate hyperglycemic control to infections? All help is appreciated.
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  2. 13 Comments

  3. by   bahamagirl
    We have insulin protocols both sc and iv. We start to treat once the bg is 8 or greater. For the iv we would bolus according to the bg i.e. 2u bolus then start the gtt at 1u/hr. We check the bg qhr until we reach a bg less than 8 for three hours in a row. If bg is greater then 8 we would bolus- using my example- 1u then increase my iv rate by 1u. We would continue this method until we reach a bg less than 8. If bg is 7.5 we would not make any adjustments. It is a bit time consuming but we have great glycemic control in our unit. I hope this helps you.
  4. by   pricklypear
    For our cardiac surg patients, we start a gtt at a BG greater that 150. We have an "intensive insulin protocol" that involves calculating the BG - 60 X (0.01-.10) We hated it at first, but once you get used to it, you find that it really does control better than our old one. Below 150 we use a sliding scale.
  5. by   zambezi
    When the patient first gets back from surgery and is vented or not taking PO we using an insulin drip. We check a BS with our frist labs when they arrive from the OR. We start insulin when the BS is 140 or higher. For diabetic patients, we start it on the frist BS > 140 and for non diabetics we start it for the second BS > 140. Once the patient is taking PO, we change them to a sliding scale. There was a really good article out a couple of years ago regarding tight insulin control and infection (as well as other things, healing times, complications, etc) but I don't have the name of it off the top of my head, I will see if I can find it at work. I posted our protocol a while back, I will see if I can find it and post it here.
  6. by   suzanne4
    The new protocol that has come out from the Society of Critical Care Medicince is actually going for much tighter controls.........most hospitals have not put into play yet, but it is suggesting blood sugars in the 70 to 110 range. And to run with an insulin drip at first. I think that it may even be to the 60 range as the lower number.

    And especially for the patient that is septic.
  7. by   dorimar
    60-90 at our hospital. Kind of freaky, but it is suppossedly evidenced practice & I guess you cant' argue with that.
  8. by   TennRN2004
    All of our CABs come out with insulin gtts. Our goal BS is 80-110. We keep them on insulin gtts until taking their first solid meal, then switch to SQ insulin. Our insulin sliding scale is something like this:

    >110 start gtt at 2 units hr
    BS 111-150 increase gtt by 1 unit hr
    BS 151-199 increase gtt by 2 units hr bolus 5 units
    BS 200-249 increase gtt by 4 units hr bolus 10 units

    We also have parameters for if the BS drops, for example, if BS drops by 40 points in an hour, we half the gtt rate.

    There are numerous studies demonstrating decreased infection rates and better healing times with tightly controlled blood sugars. I went to a nursing conference in November where a hospital did a pilot and kept CABs on insulin gtts for 3 days. They had something like a 25% decrease in infection rates using the gtts instead of switching early to SQ insulin. I also vaguely remember something about poor control of blood sugars being linked to A Fib post op, but can't remember exactly what the connection was.
  9. by   TennRN2004
    Quote from dorimar
    60-90 at our hospital. Kind of freaky, but it is suppossedly evidenced practice & I guess you cant' argue with that.
    I have heard that also. But, I think the problem with this is that when you have poorly controlled diabetics come in who are used to blood sugars running 150-200s range. They don't tolerate a blood sugar of 80-100 very well sometimes, and most are symptomatic or "feel funny" with a blood sugar 60-70s range. A healthy non diabetic very well could function fine with blood sugars that low.
  10. by   grannynurse FNP student
    Quote from TennRN2004
    I have heard that also. But, I think the problem with this is that when you have poorly controlled diabetics come in who are used to blood sugars running 150-200s range. They don't tolerate a blood sugar of 80-100 very well sometimes, and most are symptomatic or "feel funny" with a blood sugar 60-70s range. A healthy non diabetic very well could function fine with blood sugars that low.
    We are talking about post op diabetic patients. It has been demonstrated that with lower blood sugars, come fewer post op complications. I am an insulin dependent diabetic and feel funny when my sugar drops below 64, 80-100 is not that unusal, not even in poorly controlled diabetics. And most of us are on sliding scales when we are in patients. And the point of being on sliding scale is to bring our blood sugar down to the normal range.

    Grannynurse
  11. by   TennRN2004
    Quote from grannynurse FNP student
    We are talking about post op diabetic patients. It has been demonstrated that with lower blood sugars, come fewer post op complications. I am an insulin dependent diabetic and feel funny when my sugar drops below 64, 80-100 is not that unusal, not even in poorly controlled diabetics. And most of us are on sliding scales when we are in patients. And the point of being on sliding scale is to bring our blood sugar down to the normal range.

    Grannynurse
    All of our post op CABs are on insulin gtts, whether they are a diabetic or not, so we are not just talking about post op diabetics. The stress of the surgery causes even non diabetics sugars to be high. I realize the point of a sliding scale, what I am referring to is the new guidelines for "normal" blood sugar range may not be well tolerated by poorly controlled diabetics who are not used to their blood sugars running so low. Some may be able to tolerate 80-100 range and feel okay, most probably will, but the new guidelines that say 60-90, how many do you think would tolerate that range as well? That is what I was referring to.

    And yes, I know that tight blood sugar control cuts down on infection rates and improves healing time. We do have a very aggressive sliding scale to keep our blood sugars low for CABs for this very reason. If you have a big sternotomy or did a LIMA you don't want to have poor healing of the sternal wound, nor do you want less than optimal blood flow to chest region where the LIMA is if the blood sugars are too high.
  12. by   my2sons
    We use the Portland Protocol in our CVICU. We start an insulin gtt for BG >150.
  13. by   JennInColumbus
    In our unit the fresh hearts have a glucose stick as part of the first fifteen minutes post op. If they are over 150 they are placed on a gtt at 2 units with sliding scale dosage changes q2h and a bolus as necessary for levels 200 and higher. I would estimate at least 75% of our patients end up on the gtt in the first 12 hours post op, even though the majority do not have DM 1 or 2.
  14. by   nicolentony
    Our fresh hearts are on Insulin gtt once their BG reaches 120. We check it every hour and adjust per policy. We call it "the obligatory insulin drip" because it seems like everyone is on it. It's a pain in the a--, but it does cut down on sternal infections and healing time.:spin:

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