post-op question

[GingerSue]

this is hypothetical patient who is type 2 diabetic controlled by diet,

hospitalized for surgery, has nasogastric tube to suction, IV N/S 1000 mL, alternating with D5W 1000 mL

chemstrip shows 10-15 mmol/L so the doctor is notified

again one hour later it is 10-15 mmol/L so the resident is notified.

What would be reasonable treatment?

From my research so far, treatment could be either subcutaneous insulin (although there are problems with unpredictable absorption and erratic blood glucose), or insulin intravenous infusion that is more predictable and can be rapidly adjusted - either in separate infusion, or there is GIK mixture (but it can't be rapidly adjusted - the entire solution has to be changed if needed)

The resources that I've found so far are from 2005:

http://www.coa-aco.org/en/library/cl..._mellitus.html

and from 2003:

http://www.aafp.org/afp/20030101/93.html

Is there anything more recent that would be helpful?

What would be most useful for this type 2 diabetic, controlled by diet, who has a nasogastric tube, is NPO, post-op?

what is the target range for BG - one source says 6.67 - 10 mmol/L

[suzanne4, RN]

I am going to move this to the Canadian forum, as we use a completely different scale for blood sugars in the US.

Just a few thoughts from this end:

Not sure why they are alternating 0.9% NS with D5W? You do not see alternating the fluids like this much anymore, no real reason for it. With an NG tube, you would see D5/.45 NS with 20 mEq of KCl to be used for fluids most of the time, changed just for changes in the electrolytes. Because they are a diabetic, and Type 2, they should be able to handle the 5% dextrose, that is only 200 calories per 1 liter bag.

My preference would be to start with a sliding glucose scale, and 1/2 of the dose since they are NPO. If that does not control it, then go to full scale, and if that is not working, or you need tighter control and quicker, then definitely insulin drip. You are seeing them used more and more in the US after surgical procedures..........better control of glucose promotes better healing.

(In the US we use a glucoscan that gives us an exact measurement, and a completely different scale system for measuring and treating blood glucoses.)

[Fiona59]

Our unit uses the insulin drip.

NG replacement fluids are ordered at the doctors discretion as to rate an solution.

[GingerSue]

I am going to move this to the Canadian forum, as we use a completely different scale for blood sugars in the US.

Just a few thoughts from this end:

Not sure why they are alternating 0.9% NS with D5W? You do not see alternating the fluids like this much anymore, no real reason for it. With an NG tube, you would see D5/.45 NS with 20 mEq of KCl to be used for fluids most of the time, changed just for changes in the electrolytes. Because they are a diabetic, and Type 2, they should be able to handle the 5% dextrose, that is only 200 calories per 1 liter bag.

My preference would be to start with a sliding glucose scale, and 1/2 of the dose since they are NPO. If that does not control it, then go to full scale, and if that is not working, or you need tighter control and quicker, then definitely insulin drip. You are seeing them used more and more in the US after surgical procedures..........better control of glucose promotes better healing.

(In the US we use a glucoscan that gives us an exact measurement, and a completely different scale system for measuring and treating blood glucoses.)

thanks

not sure what you mean by "sliding glucose scale" - do you mean "sliding insulin scale" based on glucose level? Is this insulin that would be given sc? Other material that I've looked at refers to continuous insulin infusion at 2 - 3 U/hr.

Also, I too wondered why alternate the N/S with D5W - isn't there something that would provide for less fluctuation? I mean, there are fluids available that combine the dextrose with NS.

(Maybe this is particular question/assignment is no up-to-date?)

[HenryH0]

We use a sliding scale if they are just going to be npo for a while.

If they are going to be npo for longer than we use an insulin drip.

usually we do not give dextrose iv to a diabetic patient even if they are npo. They just usually give ringers lactate.

insulin sliding scales are effective for short term management.

if the pt is going to be npo for a while and they want to maintain nutritional control then why would they not do tpn or ppn which can have the insulin mixed into the bag

[aziah]

help me discuss the holistic care of a nurse to a dying patient

[EFAN]

the unit i work on uses the diabetic protocol where we switch the NS and D5W and rates accordingly to their glucose reading. This protocol has to be ordered by the physicians of course.