With the increase in patients on Humalog and insulin pumps, I was wondering if there are any guidelines for intraoperative management. At present, for minor procedures, patients and endocrinologists have instructed us to leave the pumps alone, do hourly glucose checks, and taught us to suspend the pump, if necessary.

What about larger cases? I just did a kidney transplant in which the patient was admitted six hours before surgery, the pump was stopped and an protocol using intravenous Regular insulin in D51/2 Normal Saline was initiated. The patient’s sugar rose to over 300 mg/dl [16.7 mmol/L] before it was slowly brought down to 80 to 100 mg/dl [4.4 to 5.6 mmol/L] via the protocol. What do you foresee in the future? Will Humalog replace Regular insulin for hospital management? Can Humalog be titrated IV?

In fact, Humalog and Regular act identically when given intravenously. However, I think that you need to be able to get blood sugar levels more frequently than hourly. Within the next few years, when the continuous readout blood glucose sensors become available, we will no longer be dependent on laboratory turn-around time. In the interim, any meter approved for ancillary blood glucose testing will suffice.

DOB
Additional comments from Stephanie Schwartz, diabetes nurse specialist:

It seems to me that the insulin drip protocol (using either Regular or Humalog) should be started at a very low rate prior to disconnecting the insulin pump. You need to remember that the Humalog used in an insulin pump will pretty much be out of the patient’s system within two to three hours, so that discontinuing the pump longer that might have caused the blood sugar to rise to the level you describe.

SS

[Editor’s comment: There is general agreement that insulin by some sort of infusion is better than intermittent subcutaneous or intravenous injections during major surgery, but very little in the way of consensus on what the exact protocol should be. In my opinion, any protocol should include:

Starting of the protocol before surgery, not in surgery, to get things stabilized.
A written protocol, that any staff person can pick up with and continue, if there’s a change of personnel.
Frequent blood sugar checks (by intra-arterial catheter {“art line”} seems to work fine, if one’s available). Frequency should be at least hourly during crisis situations, and more often if feasible.
Regular insulin (or Humalog) intravenously.
Use of a “bedside” meter that’s been approved for use in a hospital, by appropriately trained staff.
A “target range” for what sugar levels are desired under the circumstances, and instructions for what changes to make if the values are outside the target range.
Tabulation or graphing of the blood sugar results and insulin doses utilized.

Finally, don’t be surprised if massive doses of insulin (maybe in the range of 15-20 units/hour) might be needed to counteract the stresses of surgery and the possible use of corticosteroid therapy.

WWQ]