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MANAGEMENT OF PATIENTS WITH DIABETES UNDERGOING DAY CASE SURGERY

General information

• Fast from midnight
• Aim for surgery on morning list
• Check a finger prick glucose before and after the procedure
• Elderly or infirm or patients with unstable control may require admission on previous day and will require a G.K.I. infusion
• If rapid recovery expected and patient to be eating normally by lunchtime, intravenous insulin infusion is not necessary
• If patient is unable to tolerate diet and/or blood glucose is > 14 mmol/L commence G.K.I. infusion
• Prevent hypoglycaemia in people prescribed oral hypoglycaemic agents and insulin
• Monitor blood glucose and ensure appropriate treatments for hypoglycaemia are available.

Diabetes treated with tablets

• Omit Metformin (if prescribed) on evening before procedure
• Omit morning tablets for diabetes
• Resume diabetes medication as prescribed with food following procedure
• See patient guidelines for restarting Metformin

Diabetes treated with insulin or insulin with metformin

• Omit Metformin (if normally prescribed) on evening before procedure
• Fast from midnight
• Continue basal (long acting) insulin as prescribed for people with type 1 diabetes. Basal insulin preparations include Lantus, Levemir, Insulatard & Humulin I given on the evening prior to surgery
• Omit morning insulin (except basal insulin)
• Resume normal insulin with food following procedure
• See patient guidelines for restarting Metformin
• If BD insulin regimen is restarted at lunchtime it is recommended that half of the normal ‘breakfast’ insulin dose should be prescribed with lunch after procedure

For further information on Diabetes and Surgery, see Handbook Section on Perioperative Guidelines

GLUCOSE - POTASSIUM-INSULIN INFUSIONS – G.K.I.

Guideline for G.K.I. infusion for patients who have to fast for a procedure

1. Check U&E’s
2. Check finger prick blood glucose (BG)
3. Add short acting insulin (e.g. Actrapid or Humulin S) to a 500 ml bag of 10% Dextrose + 10 mmol/l KCL. The amount of insulin added is determined by the finger prick blood glucose (BG) recording as shown below

   BG mmol/L	Units of Insulin
   < 4.0	Seek help – Patient may require 50 ml of 50% dextrose IV prior to commencing G.K.I.
   4.0 - 6.9	10 units
   7.0 – 12.9	15 units
   13.0 – 17.0	20 units
   > 17.0	Seek help – sliding scale insulin infusion may be more appropriate.

4. Omit KCL if there is significant renal impairment (eGFR < 30). You may also need to reduce the volume of fluid given as the above delivers 100 ml/hour. Contact the Diabetes team or Renal team for further advice.
5. Infuse the 500 ml bag over 5 hours.
6. Blood glucose (finger prick) should be checked after 1 hour and then 2 hourly thereafter and the insulin changed according to the blood glucose (finger prick) by replacing the infusion bag with a NEW bag containing the correct insulin concentration.
7. K+ should be rechecked 6 hours after commencing the infusion and then daily if the infusion is to be continued.
8. Some patients, e.g. very obese, those receiving high dose steroids or those with active infection, may have much higher insulin requirements – please contact the Diabetes team for advice (see below).
9. Once patient is eating normally return to the patient’s usual insulin or tablet regime. Monitor finger prick blood glucose 4 hourly until blood glucose is stable (4-7 mmol/L).

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