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Appendix 1 - Glucose/Potassium/Insulin (GKI) Infusion

• Take a 500-ml bag of 10% Glucose and add short acting insulin according to the table below. The insulin should be injected into the bag and mixed thoroughly.
• Add 10 mmols of Potassium Chloride to each bag. NB Omit potassium if patient has renal failure or pre op potassium > 5 mmols/L
• A pre mixed bag of 10% Glucose with 10 mmols of Potassium Chloride may be used if available.
• Monitor potassium carefully
• Run infusion at 100mls/hour, via infusion pump, e.g.-Braun, IVAC.
• Each change in units of insulin per bag requires a new bag.
• Target glucose 7-10 mmols /l.
• Optimal glycaemic control will aid recovery
• It is not acceptable to allow blood glucose levels to be consistently greater than 10mmol/L and hypoglycaemia < 4mmol/L should be avoided

• If blood glucose levels in the hypoglycaemic range, i.e. <3 mmols/l, run in 50 mls of 10% glucose and re-check blood glucose before adding insulin
• If the patient is obese or on steroids, add an additional 5 units of insulin to each bag
• If the patient has significantly impaired renal function (eGFR < 30), seek advice as they may need a reduced insulin dose or a reduced infusion rate.
• Check fingerprick blood glucose immediately pre-op and again immediately post-operatively. Once stable, the post op blood glucose may be checked 2 hourly
• Recheck K+ on afternoon of operation, then urea and electrolytes daily if infusion continues
• Change to subcutaneous insulin when eating normally. It is important to continue the IV insulin infusion for 60 minutes after the first subcutaneous insulin injection has been given
• Patients previously on oral hypoglycaemic agents should usually be changed from insulin to their normal regime prior to discharge
• If diabetes pre previously poorly controlled (HbA1c >9%) please refer to the Diabetes team for advice

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Appendix 2 - Insulin via Pump (sliding scale) with Glucose/Potassium Infusion

• This is an alternative to the GKI infusion which is more suitable for very ill patients peri- or post-operatively
• Note it involves separate infusions of glucose and insulin and appropriate precautions taken to ensure both remain infusing e.g. by using a Protect-A-Line 2 Extension set, with anti-syphon and anti-reflux valves
• The blood glucose and urea and electrolytes should be monitored as above
• 10% Glucose is infused at 100mls/hour (or less if renal or cardiac failure or raised intracranial pressure)
• Add 10 mmols of Potassium Chloride to each 500 ml bag of 10% Glucose unless patient has renal failure or pre op potassium >5mmols/l. Monitor potassium carefully
• A separate infusion pump with 50units of Actrapid in 50mls 0.9% saline is infused simultaneously. This is infused at the following rate

• Optimal glycaemic control will aid recovery
• Agree individual blood glucose level targets e.g. 7-10mmol/L and ensure IV insulin ratio in sliding scale is altered if this target is not being achieved
• Occasionally the regime has to be adapted for a specific patient
• It is not acceptable to allow blood glucose levels to be consistently greater than 10mmol/L and hypoglycaemia < 4mmol/L should be avoided

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Appendix 3 - Multiple Injection Regimen

A multiple injection regimen should consist of:

• short acting soluble insulin (e.g. Humulin S or Actrapid) taken 30 min prior to meals with intermediate acting insulin (e.g. Humulin I, Insulatard) administered at 10 p.m.
• alternatively a rapid acting insulin analogue e.g. Insulin Lispro (Humalog), Insulin Aspart (Novorapid) or Insulin Glulisine (Apidra) may be injected immediately before main meals and is combined with a long acting insulin analogue e.g. Insulin Glargine (Lantus) or Insulin Detemir (Levemir). The latter is most commonly taken at teatime or bedtime, although less commonly, some patients do so at breakfast time

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Contacting the Diabetes Team

Ideally difficult cases and patients undergoing major operations, particularly if insulin treated, should be discussed with the Diabetes team, well in advance if possible. There is an on call service for advice available Monday - Friday during working hours at both Ninewells and PRI sites. Out of hours advice may be obtained from the Medical On-call team (contact Switchboard).

Ninewells Hospital

Diabetes Specialist Nurse: ext.36009 or page 4872

Diabetes Specialist Registrar: page 5416

Perth Royal Infirmary

Diabetes Specialist Nurse: ext.13476

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