Surgery and Insulin use


#1

I decided to start this as a lot of people ended up talking about having surgery and insulin dosing on a different subject blog. I have to assume that there are a lot of people out there that would love other peoples experiences so they have a better idea of how to handle it. It was very frustrating and scary when I had surgery a few years ago trying to figure out what I needed.

I was on Lantus once a day and Humalog as needed. For the first outpatient surgery it was going to be a short surgery I was told to take my full dose of the long lasting and none of the fast acting. I was fasting of course and I tested my sugars all morning and went into surgery at about noon with around a 200 BG level. My BG shoots up every morning without eating it turns out. When I woke up about an hour and a half later. I asked them to test my sugar and I was in the 70’s, so they gave me some apple juice and I was a fool because they offered me a second one and I drank it! Of course they then tested me again and I was around 350. My fault but it tasted so good! But sigh at least I wasn’t low anymore. I was going home so it was easily fixable as soon as I got to the car.

Outpatient surgery the second time around a couple of weeks later, the consultant pre surgery said they usually tell everyone take the full dose of long lasting. But I e-mailed my endo about the first surgery drop and she said this time try a half dose of the long lasting, no fast acting. This surgery was going to be about 3 hours and didn’t occur until almost 5:00 pm because the Dr was flying in to do the surgery. I went into surgery with a BG of around 225. When I was wheeled in I asked if they test me doing surgery and they said normally they don’t. Okay panic, I asked them to please test me during surgery as I dramatically dropped the first time. So they agreed. I came out with about a 150 BG.

Surgery is scary enough but they didn’t seem to have “special” protocol for Type 1. Testing me during this surgery seemed like it should have been standard treatment. And this was at a well known large hospital.

If I have to have any future surgeries I am now on a pump and a CGM which has turned out to be a wonderful thing! Especially the CGM part! But it will be another new learning experience. I also drop when I am in the dentist chair, drastically sometimes and have had dental surgery now using a pump. I have experimented with both a temp complete suspension and temporary half dose and both have worked out well. I dropped still but not into a too low situation.

So let people know how you handled your BG for surgery and how you did. I would have loved having more information from people! We all can be so different and the more knowledge the better!


#2

I have surgery this week and I am kinda nervous about it. Last time I had surgery, probably 9-10 years ago, I was still not being very aggressive about my management, so I am sure I was high during it and didn’t have to worry about dropping. Now i am more aggressive and it is a concern. I think they will let me keep the pump, which also is my CGM, on for it though.


#3

In the past I have taken half my Lantus dose. And I always make sure that I am the first surgery of the day.


#4

Last time I had major surgery it was for a major abdominal thing and I think the whole procedure took about 4-5 hours. I was still on Lantus-Novolog then, no CGM, and I think I was told not to take any insulin beforehand. I was scheduled first–whenever I’ve had surgery they’ve shifted me to the top spot as soon as I inform them I’m insulin dependent. I don’t recall there being anything else by way of accommodating or regulating my BG, and it was a long time in the ICU before I could do any testing. I was pretty groggy and I don’t remember much about that first 6 hours or so, except that as they moved me to my room someone asked if I ever have nausea after anesthesia, to which I answered “not that I know of” and then promptly vomited all over myself.

The big pain was that they wanted to treat me with sliding scale R/N while I was in-patient (a three day stay). It’s a pretty standard rule that you’re not allowed to dose yourself with any medications while you’re under hospital care, for reasons of liability among other things, but I was shocked when they brought those vials out. I had brought my own pen injectors, expecting to take care of my T1 myself (it had nothing to do with what I was in there for), and it turns out that’s a no-no as well. I’d only been out of R/N prison for a few years and I absolutely dug in my heels. Made enough of a stink about it that we worked out an agreement where I would dial in my own doses and let them do the actual “administering” in order to satisfy the rules. Of course that was an absurd fig leaf and in reality they let me do it all myself.

This doesn’t come up for out-patient procedures, but if you’re planning an in-patient stay you should definitely get this all worked out ahead of time. My experience was at Brigham and Womens hospital in Boston, affiliated with Joslin (as was my primary care practice at the time), so it was pretty shocking they were so backward, but it actually makes sense from their p.o.v.: basal-bolus MDI requires a lot of patient-specific knowledge to administer (carb ratios and all the rest), while R/N is a much looser thing and more easily standardized for non-specialist staff. My experience was about 10 years back, but I think it’s still something you can run into if you’re on MDI.

From what I’ve heard, it’s not an issue if you’re using a pump. I gather that—probably b/c pumps are categorized as a prosthetic device, not a medication as such—the standard is to just let you use it as normal. I don’t know if they’d have wanted me to suspend/detach it (or my CGM) during extended surgery–I tend to think a CGM, at least, would be more helpful to them than otherwise. Maybe someone with more recent experience of major in-patient surgery can weigh in. As far as day procedures involving anesthesia go (colonoscopies, e.g.) they’ve just had me hold the pump in my hand resting on the bed.


#5

I have had a few hospitalizations over the years. I have always told the hospital that I would be managing my own diabetes care while I’m there with my own insulin and my own meter, that I would write everything down for them - date, time, blood sugar reading and dose, and that they were welcome to look at the log any time they wanted. And that’s all there was to it. No one has ever given me any trouble with it. That includes my local community hospital and a couple of big Boston hospitals. You have to be firm with these people.


#6

This is hilarious.


#7

If I am put out, I am usually told to arrive at surgery at a given level. I then communicate to the Anesthesiologist and let them knwo they have it during surgery. I take it back post surgery.

If not out, I usually go in about 150 and test immediately after.


#8

On March 19th I had a total knee replacement under spinal anesthesia. Three hours before surgery I dialed my basal (on an insulin pump) to 70%. This was spot on as I went a little higher than my target of 100 but never more than 140 throughout surgery and until I was ready for my first meal, at about 6 hours postop. The order was written that I’d manage my insulin needs and delivery but report what was given to the staff. I also wore a CGM and the staff in the OR, particularly, got a real kick out of that bit of technology. What I did find though is over the next week I needed to up my basal from 0.6u/hr to 1.2u/hr. So, twice as much as usual. It was in response to pain. Steroids were held from the usual protocol and my IV fluids contained no dextrose. And after the first week of higher than normal basal insulin, I could dial back. I’m now a little over three weeks post op, my numbers are fine, and my insulin requirements are at baseline, pre-op levels.


#9

I’ll also add that I was somewhat surprised at the first tray I was given. It was a liquid meal of juice, jello, and sherbet. Holy cow! I kindly explained how that would cause some issues and asked for some broth instead. A lot of broth. It was delicious and within hours I was given a menu where I could make choices that worked for me. Be careful what you eat post-op. They don’t seem to get that low carb is important even after surgery.


#10

I’m having TKR two weeks from today and I’m a bit nervous about the bg issues, although my PCP is going to alert the hospital that I am to manage my own insulin and tests and he’s even going to come in right after surgery to make sure everything’s going okay. I’m just not sure what to do about my basal rate. The last time I had surgery (and it was day surgery and fairly minor), my bg’s kept dropping, and I had to keep shutting off the pump. Your idea of reducing your basal by 70% a few hours before sounds like it may work for me, too.

I’m less concerned about the post-surgery bg’s, as I can always correct and if I need to do it too often, I’ll raise my basal rate until I can maintain good control.


#11

70% seems to be the standard basal advice given to pre-op patients at the University of Michigan hospital, where I had my surgery. The orthopedic, anesthesia and endocrine clinics came up with that one with the understanding that it was a good place to start and close surveillance would then fine tune as needed. 70% just happened to be spot-on for me and no tweaking was needed. Good luck with your surgery @Ruth4! I had mine four weeks ago today and life is good. Pretty much back to baseline activity and almost pain-free.


#12

How was all this protocol set up? Who wrote the order? Was it your endo, the hospital’s staff endo, or maybe the surgeon?

Your account makes it seem like the policy was already in place and your situation simply triggered it. Please share how you negotiated your management of your diabetes in the hospital with hospital staff being placed into the role of receiving diabetes treatment actions initiated by you.


#13

When I had my double by-pass surgery they told me to take the long acting dose the night before and they would check it before the surgery. During the 3 days in the hospital they check it every 45 minutes to 1 hour 24 hours a day. they gave the insulin thru the IV. The levels where good ( best I ever had). They were good about making sure everything was ok.
Just make sure they know your condition when setting up the appointment and day of check in at Preop.


#14

Were you in the intensive care unit when you were on IV insulin? It’s my understanding that hospitals in the US do not generally administer IV insulin when the patient steps down to a general-care floor.

I’ve also read that IV insulin is capable of great blood glucose control but requires more frequent attention of the nurse.


#15

My surgeon knew from my first pre-op appointment that my A1c was stable at 6.1. He knew about the tech I was using and my long term control. I saw my endocrinologist two weeks before surgery (routine appointment but nicely timed) and she put a comment in the chart notes that she thought I’d be a good candidate to self-manage my own diabetic care while in the hospital. At my pre-op physical, with Internal Medicine, the fellow agreed and also made a note agreeing with that assessment. So, when I got the pre-op call the only question I had was how much of a basal decrease they’d recommend and when that should be started. I thought their advice was reasonable so I followed their protocol.

When I arrived for surgery my fasting glucose was 120, if I remember correctly. This was a little higher than I’d normally like but perfect in context. That entire day went great. On arrival in my hospital room the orthopedic resident came into my room, assessed my level of awakefullness and awareness, and asked me if I was okay to make my pump/insulin/food decisions. I’d only had a spinal with very minimal sedation (watched my surgery on the monitor!) so I answered “yes” and was good to go. The order was written that I’d make my own decisions and manage my pump and cgm and report my status to the nurses so that my care could be charted appropriately. The nurses were thrilled. The docs were happy. And I was relieved.

Now, I’m a realist here and a 40 year veteran of nursing in the ER and ICU. I also told everyone along the way that if they thought I was not compos mentis that they were to do what they thought was right. This never became a competition or antagonistic - that would be kind of stupid, actually.

As to a global hospital rule regarding patients managing their own tech and treatment - there is room to individualize how this goes. All the best rules are like this.


#16

Thank-you for the back-story. I take from this that the preparation and meetings in advance help set up an ideal situation from the diabetic patient point of view. Do you think you were treated any differently due to your profession? Was professional courtesy a factor?


#17

I think my level of diabetic competence made a difference and not so much that I was a nurse or a retired employee of the same hospital. Heck, I know a couple of nurses who take terrible care of themselves and giving them carte blanche would be negligence. Sad, but true. Nope, I think this all relates to my being able to show I know myself very, very well. I suspect any other diabetic doing the same would be given the same courtesy and I witnessed that happen in a number of instances over the years. I wasn’t a one up.


#18

That’s good to know. Sometimes when I interact with medical professionals they seem more influenced by their long and sometimes painful experience with the more typical diabetic patient. It can sometimes be tough to break through that perception.


#19

Dazzle them with those charts and graphs! And I know you have some great ones, @Terry4. :wink:


#20

Hi Terry,

When they put me in the standard hospital room for recovery it was administered in the standard IV pick in your arm. They would sent a nurse’s aid to check the level and if it was high or low the nurse would inject the insulin in the pick ( right to the blood stream if needed. The levels where good and like I said on the post they would monitor my levels every 45 to 60 minutes even in the middle of the night! (pain in the butt being woke up every hour!) I had a double by-pass (widow maker operation). The operation was done by the Da Vinci robotic machine with the surgeon at the controls. They did not crack my chest (standard way of heart surgery before the machine came out) to do it. Recovery time was only a week altogether . I had been a diabetic for 15 years before the surgery and shots where the standard for me until last year now its the pump.

With the IV the insulin works faster and its not dealing with fatty tissue before its gets in the blood stream. I was told they were using the same insulin that I was using before I went in except no long acting (lantus at the time).