1. Diabetes, Surgery and GKI’s Maureen Wallymahmed Nurse Consultant - Diabetes

2. National Service Framework Standard 8 All children, young people and adults with diabetes admitted to hospital for whatever reason will receive effective care of their diabetes. Whenever possible they will continue to be involved in the decsions involving their diabetes.

3. Prevalence of in-patients with diabetes Aintree Hospitals 1990-2009 Masson et al Diab Med 9, 753-755 Wallymahmed et al Diab Med 22, 107-109

4. Diabetes and Surgery Problems Hyperglycaemia Hypoglycaemia Erratic blood glucose control

5. Surgery – metabolic response Surgery  Trauma Stress Release of ‘stress’ hormones Hyperglycaemia Type 1  ketosis

6. What do we need Simple and safe protocols Morning surgery if possible Frequent blood glucose monitoring / acting on results Target blood glucose levels 6-11 mmol/l Restart usual medication/ Insulin as soon as eating and drinking

7. Glucose -Potassium - Insulin (GKI’s) What is a GKI 500mls 10% Dextrose 10 - 15 units soluble insulin (Actrapid) 10mmol KCL Infused at 100mls per hour Aim for blood glucose levels 6-11 mmol/l

8. GKI When to use: Insulin treated patients having surgery Type 2 patients having major surgery Insulin treated patients - fasting Type 1 patients can’t tolerate diet/fluids (short term) DKA / HONK in recovery phase

9. GKI NOT used to control blood glucose in a patient with hyperglycaemia who is otherwise WELL and Eating Review treatment, may need: Increase in OHA’s (type 2) Insulin on a temporary basis (eg. Infection) Patients on insulin increase insulin Seek advice from Diabetes Team

10. GKI REMEMBER If BG is initially high eg 14+ put more insulin in the bag eg start at 15 - 20 units. If BG is eg 20+ a GKI may not be appropriate – Seek advice

11. Problems with GKI’s Inappropriate use Often continued when patients are eating and drinking as BG ‘not stable’ Varying different regimens used in the trust – despite being available on intranet

12. Making up a GKI Refer to ‘Safe use of insulin’ guidelines on intranet Important points: Standard insulin syringe will not clear the IV additive bung (needle too short) Decant insulin from insulin syringe into standard 1ml syringe (via neck) Place green needle onto 1 ml syringe, inset into IV glucose bag via IV additive bung and draw back some fluid from the bag to mix insulin and glucose in the syringe. Once mixed inject the mixed solution back into the bag

13. New GKI Prescription Chart

16. GKI’s DO Prescribe a new bag if there is a trend towards falling or rising BG levels Ensure patient is tolerating diet and fluids before restarting usual treatment Give subcutaneous insulin 30 minutes before stopping GKI – see advice on new chart

17. GKI DON’T Alter the rate of the GKI from 100mls/hr in response to fluctuating BG -INEFFECTIVE Stop insulin unless serious hypoglycaemia – if BG < 4 treat as hypo – review insulin in bag

18. Any questions