Gloucestershire Hospitals

NHS Foundation Trust

TRUST PROTOCOL
DIABETES IN ADULTS BEFORE, DURING AND AFTER SURGERY
IMPORTANT NOTE:
Maintaining the safety of diabetic patients during surgery is essential. Read this document
thoroughly and ensure you refer to the appropriate patient directions given in the tables referred
to in Section 9.
1.

INTRODUCTION

This protocol is designed to assist medical and nursing staff in achieving the best management for
diabetic patients before, during and after surgery or other operative procedures.
The prescribing of insulin and fluids is a medical responsibility; the implementation of the prescription is
a nursing responsibility this document therefore applies to both groups to achieve ideal clinical
management of diabetic patients. This is essential for clinical governance and achievement of National
Service Framework standards.
The objective of this protocol is to maintain the glucose control and safety of all ADULT patients with
diabetes when undergoing surgery. This includes patients with Type 1 and Type 2 diabetes.
Some of the content of this protocol has been devised in response to incident reports of insulin
infusions being set up incorrectly pre-operatively.
2.

DEFINITIONS

Word/Term
Type 1 diabetes
Type 2 diabetes

3.

ROLES AND RESPONSIBILITIES

Post/Group
Consultant Anaesthetist
Consultant Physicians
Anaesthetist
Recovery Nurse
Surgical team
Pre-operative assessment
nurse
SAS or DSU admitting nurse

4.

Descriptor
Develops when the insulin-producing cells in the body have been destroyed and the body
is unable to produce any insulin.
Develops when the insulin-producing cells in the body are unable to produce enough
insulin, or when the insulin that is produced does not work properly (known as insulin
resistance)

Details

Review and maintenance of this protocol

Contribute to review and maintenance of this protocol

Diabetic control of the patient on the day of surgery

To set up the VRIII with the anaesthetists prescription

Oversee the return of the patients normal diabetic control when the patient is eating
and drinking

To give admission advice about omission of drugs and to refer poorly controlled
diabetics to their GP for tighter control

To take a capillary blood glucose (CBG) on admission (and dip the urine for ketones
is over 15 mmol/L

To give corrective dose of insulin if the CBG is over 15 mmol/L

CHANGES TO ESTABLISHED PRACTICE MAINTAINING PATIENT SAFETY

New practices to help limit the number of incident reports are:

Patients are all admitted on the day of surgery if possible, even those who have been referred to
their GP for tighter control.

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5.

6.

Corrective dose of 3 units Actrapid insulin SC is given soon after admission if CBG is over 15
mmol/L (see below).
Patients surgery is cancelled if their CBG is 20 mmol/L or over.
The intravenous insulin (via sliding scale) with Glucose/Potassium Infusion is now called the
Variable Rate Intravenous Insulin Infusion (VRIII).
The VRIII will be started after induction of anaesthesia by the anaesthetist (or in the recovery ward
for short procedures). Or not at all if patient is only missing one meal and CBG remain in the ideal
range.
The glucose containing fluid in the VRIII has changed to Dextrose 5%/KCl 0.15% (10mmol/500mL)/
NaCl 0.45% 500 mL at 100 mL/hr. This is to reduce hyponatraemia.
Long acting basal insulins are now continued pre-op and post-op at the normal times to give better
control. Glargine (Lantus), Humulin I, Insulin Detemir (Levemir). The anaesthetist should prescribe
this on the drug chart for post-op administration.
PRE-OPERATIVE ASSESSMENT
All diabetic patients scheduled for elective surgery should visit a pre-op assessment clinic. They
should have a CBG taken and, in addition to other blood tests, an HbA1c which is a guide to long
term glycaemic control.
Poor glycaemic control is associated with longer inpatient stays, poor healing of surgical wounds
and increased risk of infections. Poorly controlled patients (Type 1 or Type 2 diabetes) with a CBG
of 15 mmol/L or over at the pre-operative assessment clinic or a HbA1c of over 69 mmol/mol (8.5%)
(This blood result will be ready to be checked a few days after clinic by the pre-op assessment
nurse) should:
o Have a letter written to their GP (or to their Diabetic Consultant if they are receiving secondary
care) by the pre-op assessment nurse (include these results).
o Make an urgent appointment with their GP for tighter control of their diabetes (the patient can do
this). Or to their Diabetic Consultant (if they are receiving secondary care) by the pre-op
assessment nurse (include these results).
o Delay their admission date by 2 to 4 weeks to achieve better control.
o These patients should now be admitted on the day of surgery (not on the afternoon/evening
before surgery and not be seen by the Diabetic team on admission).
Poorly controlled patients scheduled for surgery that cannot be delayed (cancer surgery) should be
discussed with their anaesthetist by telephone pre-operatively for an action plan, which may require
admission the day before surgery for VRIII.
The Diabetes Team will NOT see pre-op patients routinely. However they can be e-referred to the
Diabetes Team should there be any urgent issues.
ADMISSION ARRANGEMENTS
Patients will be first on the operating list, preferably in the morning. Only one diabetic patient for
each list.
Diabetic surgical patients (Type 1 or Type 2) will be asked to attend Surgical Admissions Suite
(SAS at GRH, Pamington Suite at CGH) on the morning of surgery in the normal admission process
for that unit.
Those day cases that could go to Day Surgery Unit (DSU) can still go to DSU on the morning of
surgery in the normal admission process for that unit (not the Orchard Centre in GRH).
Patients may still be admitted to the surgical ward on the morning of surgery if that is the process
for their surgical team.
Oral hypoglycaemics should be omitted on the day of surgery
Long acting insulins such as Glargine (Lantus), Humulin I, Insulin Detemir (Levemir) or any other
basal insulin should be continued. (Indeed, should be continued throughout their admission.)
For morning lists omit short acting and mixed insulins on the day of surgery.
For afternoon lists take normal short acting (prandial) insulin at home with breakfast or if on premixed insulin regimes (see below for examples) take half usual morning dose at home with
breakfast.

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7.

8.

ON ADMISSION
The VRIII will be started after induction of anaesthesia by the anaesthetist (if indicated).
A CBG is taken soon after admission.
CBG levels should then be checked hourly.
The anaesthetist is the responsible doctor for their diabetic control.
If CBG less than 15 mmol/L then proceed with surgery as planned.
If CBG over 15 mmol/L then dip urine for ketones.
Surgery is usually cancelled if:
o urine ketones are 3+ or more
o patient is obviously unwell
o CBG 20 mmol/L or over (elective cases).
Patients with urine ketones of 3 + or more may have Diabetic Keto-Acidosis (DKA) and should be
discussed with the diabetic team.
If CBG over 15 mmol/L (with less than 3+ ketones) give the corrective dose of Insulin SC as soon
after admission as possible. The corrective dose is 3 units Actrapid insulin SC prescribed by the
surgical team or the anaesthetist (who ever arrives earliest). This should reduce the CBG to less
than 10 mmol/L in one or two hours. This corrective dose should only be given once.
Recheck CBG in 1 hour and anaesthetist will start VRIII after induction of anaesthesia as usual.
If at any time the patients CBG is less than 4 mmol/L follow the hypoglycaemia protocol. (If there is
no IV access give glucagon 1 mg IM. If patient has IV access administer 250 mL of 5% Dextrose
(Glucose). Measure the CBG 15 minutes later after IV access. Further glucose may be necessary.)
VARIABLE RATE INTRAVENOUS INSULIN INFUSION (VRIII)
The VRIII is set up by the nursing staff in the recovery ward (PACU) following the anaesthetists
prescription. Usually after induction of anaesthesia. Use the Prescription of Intravenous Infusions of
Insulin chart (GHNHST/X709). These forms are kept in the anaesthetic room and recovery ward
(PACU).
An electronic volumetric pump is used for the Glucose infusion and a syringe driver for the insulin
infusion. The two infusions are administered using the current extension set for two infusions
through one cannula with anti-siphon and anti-reflux valves. (The danger of using two cannulas is: if
the cannula with glucose tissues then the patient could receive IV insulin without glucose.)
The fluid prescribed with the VRIII should routinely be 500 ml 5% dextrose / KCl 0.15%
(10mmol/500mL)/ NaCl 0.45% (pharmacy code number GV332) at 100 mL/hr via volumetric pump.
This causes less hyponatraemia than 10% Dextrose without saline. (Anaesthesia 2008; 63:1043-5).
However, 500mL 10% Dextrose with 0.15% KCl (10mmol/500mL) at 50 mL/hour may be considered
in cardiac failure.
As a general rule VRIII is not started pre-operatively. The anaesthetist will start the VRIII after
induction of anaesthesia if indicated (see below). Or, for short operations, in the recovery ward after
surgery.
The ideal CBG range is 6-10mmol/L but an acceptable range is 4-12 mmol/L. CBG should be in the
ideal range on discharge from the recovery ward. VRIII need not be commenced if the CBG stays in
the ideal range (below 10).
Usual oral hypoglycaemic agents, short acting and mixture insulins should be omitted whilst VRIII is
running. See detailed guidelines for oral hypoglycaemic medications below.
Continue long acting insulins alongside VRIII post operatively - so for patients receiving Insulin
Glargine (Lantus), Humulin I, Insulin Detemir (Levemir) or any other basal insulin, such should be
continued alongside IV insulin on a daily basis at their usual time of day. Prescribe the long acting
insulin on the yellow drug chart and the VRIII on the Prescription of Intravenous Infusions of Insulin
(form X709). This would enhance quick switching to SC insulin when patient is able to eat and also
prevent DKA if the IV is inadvertently discontinued.
If the patient has advanced renal failure, the fluid infusion rate and additional KCl needs to be
discussed with the Consultant Nephrologist on call.
Monitor CBG hourly to the first 8 hours. If the CBG is stable and within the ideal range then this can
be reduced to 2 hourly.
Check U & Es daily whilst infusion running particularly to look for hyponatraemia and hypo or
hyperkalaemia.

Reference: Management of adults undergoing surgery and elective procedures: NHS Diabetes, April 2011 (Joint working party report).
DIABETES IN ADULTS BEFORE, DURING AND AFTER SURGERY
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9.

SPECIFIC MANAGEMENT OF INDIVIDUAL PATIENTS

Elective surgery this is divided into those with a longer period of starvation (missing more than 1
meal) and for those undergoing very short procedures and expected to be eating normally within
four hours
Emergency surgery is covered separately
Specific guidance is given for specific oral hypoglycaemic drugs and injectable GLP-1 agonists

NOTE:
Please make sure you are looking at the right table to manage your patient appropriately
Table 1 - Elective patients expected to miss more than one meal
Table 2 - Very short elective procedures with patients expected to be eating normally
within four hours
Table 3 - Emergency surgery
Table 4 - Specific oral hypoglycaemic drugs and injectable GLP-1 agonists

10.

All elective patients will have been offered advice and guidance during the pre-op period and will
usually be well informed about what to expect.
Many patients with type 1 diabetes will adjust their prandial insulin according to the carbohydrate
content of their food when eating. If they are well enough and wish to continue to do this on the
ward this is encouraged. If a patient is doing this it is important to ask them to note how much
insulin they are having and what their blood sugar readings are and to record these on their
diabetes treatment chart.
If a surgical patient has diabetic keto-acidosis (DKA) this must be managed carefully according to
the DKA protocol and early involvement of the diabetes/medical team is very important. Contact the
Diabetes Team in hours, or the on-call medical registrar out of hours
TRAINING

Staff are required to maintain awareness of this document and any changes made to it.
11.

MONITORING OF COMPLIANCE

Criteria
(objective to be
measured)

Monitoring methodology

Lead
responsible

Timescales

Reporting
arrangements

Compliance with
individual patient
management
guidance

Audit of post-operative
diabetic patients in
recovery wards

Head of Recovery
GRH and CGH

Annual

Anaesthetic Audit and

Clinical Governance
Committee

12.

REFERENCES

NHS Diabetes (2011). Management of adults undergoing surgery and elective procedures: NHS
Diabetes, April 2011 (Joint working party report). London: NHS Diabetes
Eldridge AJ, Sear JW. Peri-operative management of diabetic patients. London: Anaesthesia; 63:1043-5

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DIABETES IN ADULTS BEFORE, DURING AND AFTER SURGERY DOCUMENT PROFILE

DOCUMENT PROFILE
REFERENCE NUMBER
CATEGORY
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AUTHOR

ISSUE DATE
REVIEW DETAILS
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APPROVING GROUP
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KEYWORDS
RELATED TRUST DOCUMENTS

A0132
Clinical
2
Richard Vanner, Consultant Anaesthetist
Richard Vanner, Clinical Director Anaesthesia; Alison Evans,
Tripti Mahajan, Consultant Physicians
(technical authoring support, Kym Ypres-Smith)
February 2014
February 2017 review by Consultant Anaesthetist
Trust Policy Assurance Group
Anaesthetic Audit and Clinical Governance Committee
Policy application: 25/02/2014
Policy approval: 25/02/2014
N/A
Consultant Physicians, Consultant Anaesthetists
Upload to Policy Site; global email; cascaded to relevant clinical
staff
Diabetes, anaesthesia, pre-op, post-op

Table 1 - Elective patients expected to miss more than one

meal
Table 2 - Very short elective procedures with patients
expected to be eating normally within four hours
Table 3 - Emergency surgery
Table 4 - Specific oral hypoglycaemic drugs and injectable
GLP-1 agonists
Contact List

OTHER RELEVANT DOCUMENTS

EXTERNAL COMPLIANCE
STANDARDS AND/OR
LEGISLATION

DIABETES IN ADULTS BEFORE, DURING AND AFTER SURGERY

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REVIEW DATE: FEBRUARY 2017