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Integrated Care Pathway for the Management of Adult Diabetes in the Perioperative Period* Addressograph or Name Address Dob Unit no. CHI NHS Lothian- University Hospitals Division Royal Infirmary of Edinburgh St John’s Hospital Planned Procedure: Princess Alexandra Eye Pavilion Western General Hospital Specialty: Consultant Surgeon: Consultant Anaesthetist: INSTRUCTIONS Insert information into appropriate spaces as required and complete ‘Initial Key’. Do not initial until actually done! This ICP is both an action checklist and a clinical record; thus it requires a drug chart and SEWS chart. * A full protocol for the management of diabetes in the peri-operative period can be found on the ‘Healthcare A – Z’ section of the NHS Lothian Intranet: Healthcarea-zdDiabetes endocrinologyMetabolic unit handbook Date initiated: …../.…./…. PRE-ASSESSMENT CLINIC PROPOSED DATE OF SURGERY ….. / …../ ….. Diabetes type: Type 1 Type 2 Usual treatment: Insulin Tablet(s) Insulin and tablets Diet HbA1c result…………… : (if HbA1c 9%, discuss with Diabetes Specialist Nurse) Anaesthetist aware that patient has Diabetes Mellitus Ensure patient is first on the list when possible To be Nil By Mouth from: ……… on……….. SHORT Fast: when immediate post-operative resumption of oral intake is likely LONG Fast: when immediate resumption of oral intake after surgery is not planned Patient on metformin? No Yes - if Yes, to be stopped on ………/……../…… Bowel preparation information leaflets provided Name sign print profession designation NHS Lothian surgical and diabetes ICP 190208 not required date Integrated Care Pathway for the Management of Adult Diabetes in the Perioperative Period Addressograph or Name Address Dob Site : ………………………….. Unit no. CHI DATE OF SURGERY ..... / …../ ….. Peri-operative SHORT fast The following protocol should be used for minor surgery, when immediate post-operative resumption of oral intake is planned. initial Omit breakfast. Omit morning dose of insulin (and oral hypoglycaemic agents, if taking these) If blood glucose remains between 5 -12 mmol/l, take no action If blood glucose is above 12 mmol/l, consider intravenous insulin Insulin infusions are continuous and made up of: 50 units soluble insulin (Actrapid) in 50ml of 0.9% saline so that 1ml = 1 unit. Check blood glucose hourly (if on intravenous insulin) If blood glucose is below 4mmol/l give IV glucose to restore blood glucose to 5-12 mmol/l DATE OF SURGERY ..... / …../ ….. Peri-operative LONG fast The following protocol should be used for major surgery, when immediate post-operative resumption of oral intake after surgery is not planned. The patient should be first on the operation list (preferably am) Omit breakfast. Omit morning dose of insulin (and oral hypoglycaemic agents if taking these) Intravenous insulin regime to be followed Insulin infusions are continuous and made up of: 50 units soluble insulin (Actrapid) in 50ml of 0.9% saline so that 1ml = 1 unit. Time of starting intravenous insulin: 8am or on arrival in theatre Check blood glucose hourly (if on intravenous insulin) Now complete the fluid prescription and drug chart Note: Intravenous insulin infusion regime may be used on instruction of anaesthetist: protocol may be found on the intranet Note: Intravenous insulin has a half-life of 2.5 minutes, so if stopped for any length of time, hyperglycaemia will occur. Name sign print profession designation Name sign print profession designation NHS Lothian surgical and diabetes ICP 190208 date date Integrated Care Pathway for the Management of Adult Diabetes in the Perioperative Period Addressograph or Name Address Dob Site : ………………………….. Unit no. CHI Intravenous Fluids Commence 5% or 10% glucose 500ml infusion with 10 mmol of KCl at 50ml/hr 100 ml/hr (Discuss with anaesthetist, appropriate glucose concentration and rate) or initial In DCN, commence 0.45% saline/5% glucose 500ml infusion with 10 mmol of KCl at 100ml/hr Note: If the blood glucose 14mmol/l, the glucose infusion should be deferred until the intravenous insulin has lowered the blood glucose to <14 mmol/l. Additional crystalloid can be administered as appropriate volume replacement Note: The insulin and glucose infusions are given through the same IV cannula, with a non-returning valve Post-operatively for short and long fast Oral hypoglycaemic agents and subcutaneous insulin should be recommenced when feeding post-operatively is re-established initial Give subcutaneous insulin before the next meal, and discontinue the intravenous insulin no earlier than one hour after the meal The exact oral hypoglycaemic agents dose and/or type of subcutaneous insulin to be given should be discussed with the anaesthetist, medical staff, or diabetes team If restarting metformin ensure eGFR 40 mmol/l, serum creatinine <150umol/l, no hypoxia, no overt heart failure and no hypovolaemia Note any Variances from Pathway with ‘VAR’ & explain fully on Variance sheet below Name sign print profession Name sign designation print date profession designation date VARIANCES: all staff to identify & record variances. Types of Variance: break down into types: A = Patient/Relative, B = Clinician, C = Hospital System, D = Community/External. Record of Variance Date 20th June ’08 Time Description of issue Reason Action Heart Failure Reduction in fluid regime 08.30 Patient did not receive IV fluids as An example only pre-op indicated NHS Lothian surgical and diabetes ICP 190208 Initials Var. letter ABC B NHS LOTHIAN INTRAVENOUS INSULIN PRESCRIBING CHART Ward: …………Site: …………..Date: ………….. Addressograph or Name Address Dob Unit no. CHI Insulin infusions are continuous and made up of: 50 units soluble insulin (Actrapid) in 50ml of 0.9% saline so that 1ml = 1 unit. Adjusted sliding scale 1 Adjusted sliding scale 2 Suggested Sliding Scale Blood Glucose Rate (units/h) Blood Glucose Rate (units/h) Blood Glucose Rate (units/h) <4 4.0 – 4.9 5.0 – 6.9 7.0 – 9.9 10 – 12.9 13 – 15.9 ≥16 Nil 0.5 1 2 3 4 6 Doctor’s signature (print) Check capillary blood glucose hourly while on IV insulin. The sliding scale may need to be modified after 12 hours if blood glucose levels very variable and insulin doses changed frequently. If capillary blood glucose is consistent, reduce monitoring interval to 2 hourly Blood Glucose Insulin rate (units/h) MONITORING CHART Time (24h clock) NHS Lothian surgical and diabetes ICP 190208 Signature Time (24h clock) Blood Glucose Insulin rate (units/h) initial & time Signature Addressograph or Name, DOB, Unit No. NHS LOTHIAN BLOOD GLUCOSE MONITORING AND INSULIN PRESCRIPTION CHART If on intravenous insulin, please document hourly blood glucose readings on the intravenous insulin chart BG other Time Ketones Date BLOOD GLUCOSE (mmol) Before Breakfast Before Lunch Before Evening meal Before Bed INSULIN (units) Before breakfast Type/units UNITS UNITS UNITS UNITS UNITS UNITS UNITS BG chart based on Orthopaedics/RIE/diabetes ICP 190208 NEVER OMIT INSULIN Prescribed by Given by . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ……… . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Prescribed by Given by Before Lunch Type/units UNITS UNITS UNITS UNITS UNITS UNITS UNITS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Prescribed by Given by Before Evening Meal Type/units . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . UNITS UNITS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . UNITS UNITS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . UNITS UNITS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . UNITS UNITS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . UNITS UNITS UNITS Before Bed Type /units UNITS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . UNITS UNITS Prescribed by Given by . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . …………. hypoglycaemia Time and Treatment
