treatment of post-op hyperglycemia

bahamagirl · Mar 28, 2006

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.

pricklypear · Mar 28, 2006

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.

zambezi, BSN, RN · Mar 28, 2006

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.

suzanne4, RN · Mar 28, 2006

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.

dorimar, BSN, RN · Mar 28, 2006

60-90 at our hospital. Kind of freaky, but it is suppossedly evidenced practice & I guess you cant' argue with that.

TennRN2004 · Mar 31, 2006

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.

TennRN2004 · Mar 31, 2006

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.

grannynurse FNP student · Mar 31, 2006

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. :lol2:

Grannynurse:balloons:

TennRN2004 · Mar 31, 2006

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:balloons:

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.

my2sons · Apr 5, 2006

We use the Portland Protocol in our CVICU. We start an insulin gtt for BG >150.

JennInColumbus · Apr 11, 2006

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.