1. BLOOD GLUCOSE CONTROL A learning module for Staff

2. How to Use this Module Use this module to educate staff on glucose control. Sample slides have been prepared on identifying and managing patients with hyperglycemia. You may copy and paste your facility order sets and add your own key points to match your policy and protocols.

3. Blood Glucose Control Objectives 1.The importance of blood glucose control in surgical patients. 2.Understand the pathophysiology related to hyperglycemia and safety. 3.Educate staff to the policies, procedures, and protocols.

4. Why is Blood Glucose Control so Important in the Perioperative Setting?

5. Pathophysiology of Hyperglycemia GLUCOSE INCREASED GLUCOSE PRODUCTION DECREASED INSULIN PRODUCTION INSULIN RESISTANCE RECEPTOR DEFECT

6. ‘Stress’ Hyperglycemia-What Happens? Cytokines/inflammatory mediators contribute to: Inability of immunoglobulin to bind with surface of invading bacteria so decreased bacteriocidal capacity. Impaired platelet function 54% increased blood stream infections 59% increase acute renal failure requiring dialysis and 50% increase in blood transfusions. Relative hypoinsulinemia contributes to: Decreased insulin sensitivity. Unrestrained free fatty acids and hepatic fatty acids. Increased ketone bodies and metabolic acidosis. Impaired myocardial contractility and larger infarct sizes. Glycosuria induced osmotic diuresis and extracellular K+ shift. Berghe, 2001; Goldberg & Inzucchi, 2005 Adapted from Whitman, 2012 WSHA Webcast

7. Resulting Complications of Hyperglycemia and Stress Hyperglycemia Decreased tissue perfusion Impaired metabolism Impaired cardiac function Decreased wound healing Pro-thrombotic state Pro-inflammatory state Braitwaithe, et al. 2008; Adapted from Inzucchi, Magee, & O’Malley, 2010 Image retrieved from: http://pennstatehershey.adam.com/content.aspx?productId=42&pid=42&gid=000254 http://pennstatehershey.adam.com/content.aspx?productId=42&pid=42&gid=000254 Adapted from Whitman, 2012 WSHA Webcast

8. Physiologic Insulin Secretion: Basal/Bolus Concept Breakfast Lunch Dinner Insulin (µU/mL) Glucose (mg/dL) Basal Glucose 150 100 50 0 789101112123456789 A.M.P.M. Time of Day Basal Insulin 50 25 0 Nutritional Glucose Nutritional Insulin Suppresses Glucose Production Between Meals & Overnight The 50/50 Rule Adapted from Maynard & Wesorick, Society of Hospital Medicine, 2008 J. Whitman, Perioperative Glucose Control, Webcast 2012

9. Current Best Practices Insulin infusion: If NPO and unstable. Basal insulin: Covers the baseline insulin needs. Essential for all type 1 diabetics to prevent ketosis. In most cases should be given even if patient is NPO. Nutritional insulin: Covers increases in serum glucose after caloric intake. Correctional insulin: Additional to scheduled nutritional dose. Wisse, 2012 Adapted from Whitman, 2012 WSHA Webcast

10. Oral Hypoglycemic Agents STOP

11. Why Not Sliding Scale? Theoretical glucose levels with SSI Insulin BG (mg/dL) Target range Adapted from Whitman, 2012 WSHA Webcast

12. Perioperative Blood Glucose Control Protocols and Standing Orders  Perioperative Blood Glucose Control Protocol  Insulin Pump Standing Orders  SQ Insulin Standing Orders

13. Pre-Operative Period ALL patients with a blood glucose of 180mg/dl and greater. Regardless of diabetes diagnosis or not. NOT to be used on OB patients, 23 hour admits or those admitted with DKA or HHS (hyperglycemic crises) Review the protocol

14. Intra-operative Glucose Control Period Measure BG at induction and 1h into case. Anesthesia associated with hyperglycemia even in non-diabetic subjects. Measure BG every 1h in Type 1 DM patients. Method of glycemic control intra-operatively. IV insulin (DM1, critically ill, neurosurgery, TBI). Basal insulin with bolus correction doses. Some hospitals have placed glucometers on every anesthesia cart. Wisse, 2012

15. Initiate for BG >140 mg/dL x2 or >180 mg/dL range Goal range 110-180 mg/dL Standard infusions are regular insulin 100ml/100 units on a dedicated line Post-Operative Period

16. Check BG every hour until at goal Then decrease BG checks to every 2 hours Hourly checks should always be resumed if patient falls outside of goal range Post-Operative Period (cont)

17. Key Steps in Transitioning Off the Insulin Pump Do know criteria for transitioning off insulin pump DO overlap SC and IV Insulin. Minimize hyperglycemia because of short ½ life of IV insulin. DO use rapid analogs (Apidra) after meal if uncertain patient will eat. DO expect basal and nutritional insulin if patient is eating. DO ensure adequate food intake when switching patients with ketotic diabetes to SC insulin DO arrange for follow-up post hospitalization even if insulin is temporary. Carlson, et al., 2006 Adapted from Whitman 2012 WSHA Webcast Suggested Criteria BG range 90-140 mg/dL. Stable insulin infusion rate. Nutrition intake is current or anticipated. Need last four hours of insulin drip data.

18. Transition Algorithm Transition any time of day. Give basal insulin 2hrs prior to stopping IV insulin. TDD of SC basal insulin = IV units insulin used last 4 hrs x 5. Also give nutritional insulin if timing with a meal. Carlson R. et al. Chest. 2006; Adapted from Wisse, 2012 Adapted from Whitman 2012 WSHA webcast

19. Signs and Symptoms of Hypoglycemia Sweating Anxiety Confusion Hunger Dizziness Tachycardia Irritability Shakiness Trembling Pallor Headache Weakness Hypoglycemia can occur without symptoms, so it is important to check blood glucose levels regularly. Adapted from Whitman, 2012 WSHA Webcast

20. Treating Hypoglycemia: 3 Steps Give 15g of glucose or Wait 15 mins Recheck BG – give another fast-acting another 15g if carbohydrate necessary 4oz (1/2 cup) fruit juice * Assess for cause 8 oz (1 cup) milk 1 Tbsp honey IV Dextrose Goal to restore BG above 100 Avoid overtreatment (excessive amount of glucose), which may result in significant hyperglycemia over next 4-6 hrs. Adapted from Whitman, 2012 WSHA Webcast

21. PATIENT CARE FLOW SHEET: Blood Glucose Section The section of this documentation form is appropriate for all nurses to review whether they are on Med/Surg, Telemetry, or Critical Care units. Documentation of blood glucose control issues include documenting the hyperglycemia and hypoglycemia as well as the treatment. Look closely at this section:

22. Glucose Control: an Example Smooth Transition: Inpatient to Outpatient If discharging patient new to insulin: Make the decision as early as possible. Teach, teach, teach. Early follow-up a must. Pens vs. vial/syringe. If changing outpatient regimen significantly: Communicate with PCP. Document rationale. Educate patient. Wisse, 2012, Adapted from Whitman 2012 WSHA webcast

23. THE FINISH LINE!!! CONGRATULATIONS! You have finished the Surgical Glucose Control: Policies, Procedures, and Protocols Learning Module If you have any questions, please contact your Clinical Educator, your unit’s Diabetes Champion, or one of the Diabetes Educators.