Patients On Insulin Therapy

Patients on insulin therapy having anything other than a minor surgical procedure should, optimally, be admitted prior to the day of planned surgery to allow stabilization of the blood glucose levels. On the day of surgery, which, as stated above, should always be in the morning, an intravenous infusion of insulin and glucose should be set up with potassium supplementation. Most centers utilize a continuous intravenous infusion of insulin via a pump driving a syringe containing 50 units of soluble insulin made up to 50 ml with normal saline, with the rate of insulin infusion being determined by the ambient hourly blood glucose level according to a preset protocol together with a separate infusion of 5% dextrose with added potassium through either a separate line or the insulin infusion being 'piggy-backed' into the dextrose infusion line.

An alternative regimen is the GKI (glucose-potassium-insulin) regimen whereby 15 units of soluble insulin with 10 mmol of potassium chloride is added to a 500 ml bag of 10% dextrose and the mixture is infused over 5 hours. If blood glucose levels are not controlled within the target range, then an appropriate alteration to the amount of insulin delivered must be effected by substituting a newly prepared bag with a different insulin dosage. Potassium supplements in both regimens may need to be altered according to measured plasma electrolytes.

The intravenous glucose, insulin, potassium regimen by whichever method is continued after the operation until the first postoperative meal when subcutaneous insulin is administered and the insulin infusion continued for a period that will depend on the time absorption profile of the insulin administered subcuta-neously.

The above-mentioned protocols cover the broad generality of situations managed by the non-specialist. Specialist teams, with extensive experience of the management of perioperative diabetes, may modify them according to circumstances at the time.

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