General Orders for Surgical Diabetic Patients

- Preoperative:
    - labs:
            - HA1c
            - UA: r/o ketones
            - Osmolarity
    - patients on oral hypoglycemics, d/c 1 day preoperatively;
    - place on sliding scale;
    - schedule AM operation if possible;
    - start IV D5 1/2 NS: 75-100 cc/hr (D5W at 100 cc/hr only gives 400 kcal over 24 hrs);
    - AM of surgery: 1/2 of usual SC NPH and Regular insulin dose
            - in type I diabetics consider additional 1/4 Reg. insulin dose q 6hr
    - brittle diabetic: consider continuous preoperative insulin iv infusion
    - preop insulin management:
            - 1 unit of insulin disposes of about 8 gm of glucose;
            - 1 unit of glucose should decrease blood glucose by about 50;
            - most operative patients can be maintained in the 120 to 180 blood glucose
                  range w/ regular insulin infusion rate set at 1.0 unit/hour and 2.0 U/hour;
            - note: make the distinction between IDDM and NIDDM
                  - IDDM: pt must receive insulin on a routine schedule and must not be
                          be placed solely on a Sliding Scale;
                  - NIDDM: pt may be placed solely on Sliding Scale;

- Postoperative:
- Continue IV Dextrose
- Provide 1/2 usual NPH Insulin (AM and PM)
- Check glucose q4-6 hr; adjust with Sliding Scale;
- adjust insulin dose with resumption of oral diet or enteral feeding.
- resume Antidiabetic agents
- UA: r/o ketones

Original Text by Clifford R. Wheeless, III, MD.