• Guideline - Diabetes
    Link:www.diabetes.org.uk/Documents/Professionals/Reports%20and%20statistics/Management%20of%20adults%20with%20diabetes%20undergoing%20surgery%20and%20elective%20procedures%20-%20improving%20standards.pdf
    • 'Variable rate IV insulin infusion' should replace the term 'sliding scale'
    • Patients missing no more than 1 meal should be managed by modification of their usual diabetes medication, avoiding a VRIII.
    • Patients missing more than 1 meal should have a VRIII
    • The fluid of choice is 0.45% NaCl with 5% glucose and either 0.15% or 0.3% KCl
      • 0.9% saline/5% dextrose may be used in hyponatraemia patients
    • Elective surgery
      • Consider referral to diabetes team if HbA1c > 69mmol/mol (8.5%)
      • Upper limit of 64-75 (8-9%) is acceptable
      • CBG of 4-12 are acceptable but aim for 6-10
      • Consider continuation of long acting insulin alongside the VRIII
      • CSL is fine to use if VRIII is not required
      • Correct high CBG by additional S/C insulin or by introducing a VRIII
    • Management of hyperglycaemia
      • CBG > 12 mmol/L pre or post surgery
        • Check ketones
          • If ketones ok
            • TIDM
              • SubQ rapid acting insulin 1 unit will drop glucose by about 3mmol/L. Recheck CBG and after 1 hr to ensure falling. If surgery can't be delayed, start VRIII
            • T2DM
              • Give 0.1 units/kg of subQ rapid insulin and recheck CBG in 1hr and if response inadequate or surgery can't be delayed, start VRIII
          • If capillary > 3 mmol/l or urinary > +++ then cancel surgery and treat as DKA
    • Management of hypoglycaemia
      • 4-6 with symptoms
        • 50-100ml of 10% dextrose and repeat CBG after 15 mins
      • <4
        • 80-100 ml of 20% dextrose and rpt CBG after 15 mins
      • Try not to stop the VRIII but if so, restart after CBG rises above 5
    • Transferring from VRIII
      • Oral meds
        • Recommended once eating and drinking
      • Insulin
        • Restart the normal pre-surgical regime
        • The transition should take place when the next meal-related subQ insulin dose is due
        • For twice daily fixed regime
          • Insulin given at usual time (before breakfast or evening meal) and the VRIII should be continued for 30-60 mins after
        • For patients on basal bolus regimes
          • Should be overlap between VRIII and fast acting insulin of 30-60mins
          • If basal insulin was stopped, the VRIII should continue until basal insulin has been given
    • Guidance for VRIII infusion
      • If CBG > 12 for 3 readings and not falling by 3mmol/hr the rate of insulin should be increased
      • If CBG <4 then the insulin rate should be dropped to 0.5units/hr and the low glucose treated
      • The 0.45% saline/5% glucose should be set at the hourly fluid fluid requirement for the individual patient (usually 83-125ml/hr)
      • Rate of insulin infusion
        • Insulin
          • CBG
        • 0.5
          • <4.0
        • 1
          • 4.1-7.0
        • 2
          • 7.1-9.0
        • 3
          • 9.1-11.0
        • 4
          • 11.1-14.0
        • 5
          • 14.1-17.0
        • 6
          • 17.1-20.0
        • Seek advice
          • >20
      • Continue VRIII until patient is eating and drinking and back on their usual glucose lowering medication
      • Additional fluid may be required