Insulin Infusion Rate

8/12/2019 Insulin Infusion Rate

http://slidepdf.com/reader/full/insulin-infusion-rate 1/20

Uncontrolled Diabetic coming for

Emergency Laprotomy

Introduction

Diabetes refers to excessive production and excretion of urine.

Mellitus literally means honey and refers to abnormally elevated concentrations of glucose in blood

and urine

Table 344-2 Criteria for the Diagnosis of Diabetes Mellitus

Symptoms of diabetes plus random blood glucose concentration 11.1 mmol/L (200mg/dL)

aor

Fasting plasma glucose 7.0 mmol/L (126 mg/dL) bor

A1C > 6.5%cor

Two-hour plasma glucose 11.1 mmol/L (200 mg/dL) during an oral glucose tolerancetest

d

Uncontrolled / poorly controlled diabetic may usually present with complications

Asian Indians are more prone to diabetes as well as it’s complications

Certain complications like coronary artery disease and Nepropathy are more common

in Indians

Diabetics can present in any scenario

The Annual rate of Diabetic Acidosis was 46 per 10000 individuals with Diabetes. Of

these 87% were on insulin prior to admission and 81% were not Obese.

The youngest children were at greatest risk.

The prevalence of diabetic complications are given below





it as been clearly shown that better glycemic control in diabetics undergoing surgery improves out come

uncontrolled diabetic should not be taken up for elective surgery before correction of complications

CASE STUDY

A male patient aged 17 years came with

Fever with chills & rigors since 3days

SOB since 2days,

Vomitings since morning,3times,

Severe Thirst

Diabetic diagnosed 2 years back & on irregular Insulin treatment.

This case is also presented with severe abdominal pain in the epigastric area .and posted for

emergency laprotomy

O/E : Dehydrated

PR : 152 / mt

BP : 120 / 80 mm of Hg

RR : 38 / min , Tachypnoeic

SpO2 : 91% on Room air

CVS : S1 S2 +

RS : BAE+

Investigations

Hb : 17.4 gm%

TLC : 24.9 cells/ c.mm

Platelets : 4.05 lacs/c.mm

BUN : 29.4 mg/dl

S.creatinine : 0.7 mg/dl



ABG

PaO2 104.5 mm Hg

PaCO2 25.4 mm Hg

pH 7.418

Hco3 (actual) 16.0 mmol/L

Hco3 (std.) 19.1

BE -13.8 mmol/L

BE ecf -15.9 mmol/L

AG 28.1 mmol/l

S.electrolytes :

Na : 139 meq/l K : 2.6meq/l,

Cl : 114 meq/l , Ca : 8.3 meq/l, Mg 1.9 meq/l

BGL : high,

urine ketone bodies : + ve

Management

Correction of Complications

Correction of Dehydration

Correction of Acidosis & electrolytes

Correction of Hyperglycemia

Control of INFECTION

DKA

Common In type 1 DM

Symptoms :

1. Dyspnoea,

2. Abdominal pain,

3. Nausea and vomiting,

4. Dehydration,

5. Coma



Anion-gap metabolic acidosis, elevated plasma and urine ketones (acetoacetate,

beta-hyroxybutyrate), hyperglycemia

DKA –Treatment

1. Fluid resuscitation-NS@ 1L/hr for two hrs. Then 500ml/hr for 4hrs, then 250ml/hr for 4hrs .Add

D5W when plasma glucose 250 mg%

2. Insulin (regular)- 10u IV bolus is optional . 0.1 U/kg/hour infusion and increase or decrease

based on Bl.Sugar level

3. Potassium -when urine output is there

<3 meq - 40meq/hr,

3-4 meq - 30meq/hr,

4-5 meq - 20meq/hr

Insulin Infusion Rate (U / DL)Patient BloodGlucose Level(MG/DL)

Algorithm - 1 Algorithm – 2 Algorithm – 3 Algorithm - 4

< 60 = Hypoglycemia (see below for treatment)

< 70 0 0 0 070 – 109 0.2 0.5 1 1.5110 – 119 0.5 1 2 3120 – 149 1 1.5 3 5150 – 179 1.5 2 4 7

180 – 209 2 3 5 9210 – 239 2 4 6 12

240 – 269 3 5 8 16270 – 299 3 6 10 20300 – 329 4 7 12 24

330 – 359 4 8 14 28> 360 6 12 16 28



Hyperosmolar nonketotic coma

Hyperglycemic diuresis -> severe dehydration

Renal failure

Lactic acidosis

Risk of intravascular thromboses

Hyperosmolality with coma ± seizures

Treatment

Fluid resuscitation

Insulin (relatively small doses)

Potassium when urine output.

Hypoglycemia

Diaphoresis, tachycardia, nervousnessPlasma glucose < 50 mg%

Treatment: 50ml of 50% dextrose

If surgery is urgent GIK (glucose- insulin – potassium ) drip is useful to achieve rapid controlled

Anaesthesiologist encounter diabetics for

Incidental surgery

Surgery related to the disease.

Pregnancy

I.C.U



Anaesthetic Implications

Coronary artery disease

Peripheral vascular disease

Cerebrovascular disease

Renal disease

Respiratory and air way changes

Autonomic neuropathy

Cardiovascular system

Increased risk of CAD and MI

Silent myocardial ischemia and infarction

cardiomyopathy in the face of angiographically normal coronary arteries,.



Respiratory and air way changes

Significant decrease in lung volumes and diffusing capacity

Decrease in vital capacity.

Stiff joint syndrome.

Acute unexplained hypoxia in post op period.

Post op respiratory arrest.

Stiff Joint Syndrome

One of four adolescent diabetics

Stiff joints due to nonenzymatic glycosylation of the collagen tissues.

Decreased mobility of the atlanto-occipital joint.

Prayer sign

Palm print sign



Renal System

Diabetic nephropathy -up to 40 –

50% of IDDM

Albuminuria usually precedes a steady decline in renal function

Fluid and electrolyte imbalance

Delayed metabolism and altered excretion of anesthetic drugs

Autonomic Neuropathy

Up to 40% in type I & 17% in type II

Postural hypotension

Profound Intraoperative hypotension with SA requiring vasopressor support

Perioperative cardiorespiratory arrest

Exaggerated pressor response to tracheal intubation

Delayed gastric emptying with increased risk of aspiration

Signs of Autonomic Neuropathy

Lack of sweating

Early satiety

Orthostatic hypotension

Gastric reflux

Lack of heart rate variability with deep inspiration.

Impotence and urinary symptoms of Dysautonomic bladder may be evident.

Dependent oedema

Gustatory sweating



TESTS FOR ANS

• Measuring the beat-to-beat variation in heart rate during breathing,

• Heart rate response to a Valsalva maneuver,

• Orthostatic changes in blood pressure and heart rate.

• B.P response to sustained hand grip

• Changes in the heart rate – Parasympathetic system

• Changes in the blood pressure - Sympathetic system

Preanaesthetic Evaluation

• A thorough search for end-organ complications of Diabetes

• A thorough history and physical Examination

• Severity and type of diabetic state

• Medication for diabetes and control of blood sugar.

• Associated co morbidities

• Air way assessment

Investigations

• Blood Glucose,

• Blood urea ,

• Serum creatinine,

• serum electrolytes (esp-Potassium),

• Recent ECG and CXR

• Urine analysis for sugar and ketones

• Glycosylated Hb (HbA1C) to assess glycemic control



Type of Anaesthesia (Regional Vs General)

Regional anesthesia

Advantages

1. Alleviates stress response to surgery.

2. Decrease in incidence of thrombo embolism

3. Avoidance of aspiration and difficult air way problems.

4. Avoidance of poly pharmacy and their effects on diabetic status

Disadvantages

1. Cardiovascular instability

2. Exacerbation of peripheral neuropathy

3. Increased risk of infection

GA Drugs

Halothane, Methoxyflurane, and Thiopental- Nitrous oxide anesthesia, increase blood glucose

level.

Enflurane and spinal anesthesia.- no increase in bl.glucose level.

.Muscle relaxants and premedicant drugs in common use today are of little concern to diabetics

Overall, the metabolic effects of modern anesthetics are minor compared with the stress of

surgery itself



Perioperative management

The important points to consider when preparing a diabetic patient for surgery include the

- Nature and urgency of surgery, - Adequacy of blood glucose control,

- Treatment regimen used, and - Anticipated time of return to normal

diet.

The aim of perioperative glycaemia control is to avoid Hypoglycaemia, excessive

Hyperglycaemia, Ketoacidosis, and Electrolyte disturbances.

A blood glucose range between 6.7 – 10 mmol /L (120-180 mg %), is widely accepted

Monitoring

• Blood pressure,

• Temperature,

• Pulse oximetry,

• Continuous monitoring of E.C.G

•

Capnogram,

• Frequent determinations of both blood and urine glucose should be made.

• Urine out put

I.V.FLUIDS

On the basis of a preoperative osmotic diuresis, the diabetic patient may reach the operating

room with clinically significant dehydration.

In addition to the usual principles of perioperative fluid management, it is important to note the

amount of glucose administered iv to avoid a massive overdose of glucose.

Patients with diabetes should receive approximately 5 g of glucose per hour (i.e., 5 percent

dextrose solution in water infused at 100 mL per hour) during surgery to prevent the

development of hypoglycemia, ketosis, or protein breakdown



I.V.FLUIDS(cont)

It would be wrong to give large amounts of dextrose (contained in the iv solutions) just because

that patient needed vigorous fluid replacement.

N.S (0.9%NaCl) is the ideal crystalloid ,

R.L increases the blood sugar level after conversion .(k+ is given in the form of KCl)

Basing on the blood loss and Hct value fresh blood should be given

Perioperative fluid management depends up on cardiac and renal status of the patient

.

Targets of Glycemic control

Ideal to keep blood sugar between 120 – 180 mg / dL

In tight control , for selected cases between 80 – 120 mg / dL

To prevent hypoglycemia

Monitoring electrolytes especially potassium

Hemodynamic stability

Insulin therapy

Soluble insulin by I.V route is preferable

Insulin can be given either by

1. fixed rate with glucose infusion

2. separate and adjustable infusion

In well controlled diabetics, Isophane insulin can also be continued.



Diabetic Pts who are not treated with insulin

Minor Surgery + Good Glycemic Control

Replace any long acting sulfonyl ureas

Admit on the day before surgery

On the day of surgery

Operate in the morning if possible

Omit breakfast and oral agents

Avoid glucose containing infusions

Monitor blood glucose 2 nd hrly

Post Operatively

Monitor blood glucose frequently

Restart oral agents with first post op meal

Diabetic Pts who are not treated with insulin

Major Surgery + Poor Glycemic Control

Admit 2-3days before surgery

Stabilize with short acting insulin


Operate in morning if possible

Omit break fast and insulin inj

Start iv insulin &glucose( or separate line)

Monitor blood glucose 2ndhrly

Post Operatively




Transfer to sc insulin if unstable control

Restart oral agents when stabilized

Diabetic patients who are treated with Insulin

Admit 2-3days before surgery

Stabilize control if necessary


Operate in morning if possible

Omit break fast and insulin inj

Start iv Insulin & Glucose (GKI or separate lines)

Monitor blood glucose hrly

Post Operatively


Restart sc insulin with 1st

post op meal

Discontinue iv insulin 2-3 hrs later

GIK

500ML 10%GLUCOSE

10U SOL INSULIN

10MEQ OF POTASSIUM

NON TIGHT CONTROL OF BL.SUGAR

No insulin ,No glucose

Simple & still being followed by many

FBS on the morning of surgery.

Disadv- pre op glucose may be normal but intra oplevel may be high

Suitable only for brief procedure eg-dilatation, curettage & cystoscopy.

Food intake is delayed only by an hour or two



Routine management is restarted at the earliest

NON TIGHT CONTROL OF BL.SUGAR

Partial morning dose of insulin

FBS on the morning of surgery.

Partial morning dose of insulin SC and Dextrose infusion

Dis adv- SC route is not predictable : does not provide good glycemic control.

Not a very popular regimen

TIGHT CONTROL OF BL.SUGAR

To keep glucose between 80-120mg/dl

REGIMEN-1

Preprandial sugar levels on the evening before surgery.

Start infusion , piggyback regular insulin 50u in 250ml 0.9nacl

Flush this line at least 60ml of this sol to prevent adsorption of insulin.

Infusion rate = plasma glucose/150 (100-pt on steroids).

Repeat measurements of glucose 4th

hrly and adjust insulin to achieve plasma glucose of 100-

200 mg/dl


On the day of surgery-use non dextrose containing fluids for intra operative use

Determine plasma glucose 2nd

hrly and infuse insulin accordingly

Frequent change of sol pose an attendant risk of hyponatremia.

If the glucose level are < 90 mg/dl discontinue insulin and estimate the blood glucose level every30 min till glucose is >110mg/dl.

Serum k+ should be checked and adjusted accordingly with particular care for poor renal

function.




TO KEEP GLUCOSE BETWEEN 80-120mg/dl

REGIMEN-2

Fixed rate glucose infusion

Separate and adjustable infusion of insulin to maintain normoglycemia

Insulin requirements vary between 0.5 to 5u/hrly in post op period

Advantages :it is easy to follow ,but requires good communication skills between nurse and

doctor

Sliding scale insulin infusion

GGLLUUCCOOSSEE CCOONNCC IInnssuulliinn uu//hhr r iinnf f uussiioonn r r aattee

<<7700 --

7711--112255 11

112266--116600 11..55

116611--220000 22

220011--330000 33

330011--550000 44

>>550000 66



GHT CONTROL OF BL.SUGAR

The Artificial Pancreas

Close loop controlled:

The glucose and insulin are infusion is determined by an online plasma analyser

Plasma glucose level maintained between 70 -120mg/dl

Very expensive ,require complex supervision and used at present in reseach environment.

Alberti-Thomas regimen

Before operation – stabilize 2-3 days prior to surgery with short-acting insulin (Actrapid).

During operation - Give NO subcutaneous insulin on day of surgery.

Set up an infusion of 10% glucose (500ml) containing Actrapid 10 units plus KCl 1g.

Give it at the rate of 100-125ml/hr.

Check blood glucose and plasma potassium before infusion and after 2-3 hours. Adjust the

amount of insulin as follows:

Blood glucose (mmol L-1) Infusion

< 5 < 90 mg 10% glucose 500ml + insulin 5 units + KCl 1g

5 – 10 90-180 mg 10% glucose 500ml + insulin 10 units + KCl 1g

> 10 >180 mg 10% glucose 500ml + insulin 15 units + KCl 1g

> 20 >360 mg 10% glucose 500ml + insulin 20 units + KCl 1g

Adjust potassium doses according to plasma potassium level.

Disadvantage: Cumbersome and requiring periodacal alternationa

Christian Medical College & Hospital regimen

A burette set is connected to a 5% glucose (500ml) bag, and 100 ml of glucose is filled into the

burette at a time. Short-acting insulin (Actrapid) is added to the 100 ml of fluid in the buretteaccording to the scale given below and this is infused over 1 h.

Blood glucose is measured at the end of the hour which determines the amount of insulin to be

added to the next 100ml of 5% glucose.



Blood glucose mg/dl (mmol L-1) Infusion

<75 (4.1) No insulin; 100ml 5% glucose over 15 min

75-100 (4.1-5.5) No insulin; 100ml 5% glucose over 1h

100-150 (5.5-8.3) 1U Actrapid in 100ml 5% glucose over 1h




>300 (16.6) 4U Actrapid in 100ml normal saline over 1h

POSITIONING

Positioning of the pt is very important.

Injuries to the limbs or nerves are more likely as they are already compromised by diabetic

peripheral vascular disease or neuropathy.

The peripheral nerves may already be partly ischemic and therefore particularly vulnerable to

pressure or stretch injuries.

INTRAOPERATIVE HYPOGLYCEMIC SHOCK

It is virtually impossible to differentiate hypoglycemic shock from other forms of shock

intraoperatively unless supported by low blood glucose concentrations measured

concomitantly.

Treatment lies in administration of glucose, which can be given as a bolus of 50% glucose

followed by a 10% glucose-insulin infusion.



Blood sugar increases approximately 30 mg/dl for each 7.5-g bolus of dextrose in a 70-kg adult.

POSTOPERATIVE COMPLICATIONS

In addition to the usual complications, the common problems in a diabetic include poor diabetes

control and infection.

A higher incidence of cardiovascular and renal problems and autonomic neuropathy, resulting

in postural hypotension and urinary retention, may be encountered.

Overall morbidity and mortality are increased

Documents

Insulin Infusion Rate