JOSLIN DIABETES CENTER and JOSLIN CLINIC

GUIDELINE for INPATIENT MANAGEMENT OF SURGICAL and ICU PATIENTS with DIABETES
(Pre, Peri and Postoperative Care) 10/02/09
The Joslin Clinical Guideline for Inpatient Management of Surgical and ICU Patients with Diabetes is designed to assist primary care
physicians and specialists to individualize the care and set goals for adult, non-pregnant patients with diabetes who are undergoing surgery.
This Guideline focuses on the unique needs of the patient with diabetes. It is not intended to replace sound medical judgment or clinical
decision-making and may need to be adapted for certain patient care situations where more or less stringent interventions are necessary.
The objectives of the Joslin Clinical Guidelines are to support clinical practice and to influence clinical behaviors in order to improve clinical
outcomes and assure that patient expectations are reasonable and informed. Guidelines are developed and approved through the Clinical
Oversight Committee that reports to the Medical Director of Joslin Diabetes Center. The Clinical Guidelines are established after careful
review of current evidence, medical literature and sound clinical practice. This Guideline will be reviewed periodically and modified as
clinical practice evolves and medical evidence suggests.
Updates to this guideline are based upon the 2009 AACE/ADA Consensus Statement on Inpatient Glycemic Control.

Surgery Algorithm For Patients with Existing Diabetes

(The Joslin Clinical Guideline for Inpatient Management of Surgical and ICU Patients with Diabetes uses one formula for splitting the insulin;
other reasonable formulae exist and are also acceptable.)

Aim for Early Morning Booking

Day and Evening Prior to Surgery
Maintain usual meal plan and insulin dose (NPH, glargine, detemir, regular, aspart, glulisine, lispro, insulin via pump (CSII),
70/30, 75/25, or 50/50 insulin) 1C or oral antidiabetes medications 1C
Check blood glucose (BG) at bedtime; if BG >180 mg/dl, instruct patient to take insulin according to subcutaneous algorithm or
per individualized instructions 1A; if hypoglycemic at bedtime or overnight, instruct patient to treat with glucose gel 1C
Morning of Surgery
If fasting after midnight, give of the usual dose of intermediate (NPH) or 75-80% of the usual dose of long-acting (glargine or
detemir) insulin
Insulin pump (CSII) patients can continue usual basal rate 1B
Non pump users should not use rapid or short-acting insulin 1A
Omit oral antidiabetes medication 1A
Omit exenatide or pramlintide 1A
If the patient usually takes morning pre-mixed insulin (70/30, 75/25, 50/50) and is NPO, the optimal regimen would be to give
of the NPH component of the usual dose of premixed insulin and no rapid or short-acting insulin. 1B
Check BG every 2 hours before and during surgery 1C; insulin pump patients (CSII) can maintain basal rate during surgery 1B or
be changed to IV insulin infusion 1A or subcutaneous injections to maintain blood glucose target. 1A
Maintenance of Hydration
During surgery the patient should receive maintenance IV fluids without dextrose (e.g. LR or NS or NS rather than D5LR). 2C
If an insulin infusion is required, D5W at 40 ml/hr or D10W at 20 ml/hr should be started to provide adequate substrate. Patients
receiving insulin infusion should receive at least 50 g glucose/24 hours. 1C

Major Surgery

Non-Major Surgery

E.g., chest or abdominal cavity, LE

bypass, transplant, spinal or brain
surgery requiring general anesthesia,
total hip or knee replacement, surgery
anticipated to be >4 hours

Start IV Insulin

BG <80 mg/dl

BG 80-100 mg/dl

BG 101-180 mg/dl

BG >180 mg/dl

Give at least
100 ml D10W IV
or 25 50 ml
(1/2 1 amp) of D50

Begin D5W at
40 ml/hour or
D10 W at 20 ml/hour

Continue to monitor
BG every 2 hours
1C

Check BG in 15-30 min.

1C

Check BG in 1 hour
1C

Begin IV insulin
(See Pre, Intra and Post
Operative IV Insulin
Infusion Algorithm
pg. 3)
or
subcutaneous insulin
algorithm pg 2
1B

1A

(See Pre, Intra and Post Operative IV

Insulin Infusion Algorithm pg. 3)

Copyright 2009 by Joslin Diabetes Center. All rights reserved. Any reproduction of this document which omits Joslins name or copyright notice is prohibited.
This document may be reproduced for personal use only. It may not be distributed or sold. It may not be published in any other format without the prior, written
permission of Joslin Diabetes Center, Publications Department, 617-226-5815.

Postoperative Management
Check BG when patient returns to post-anesthesia unit 1B; base frequency on BG during surgery 1C
Administer insulin according to subcutaneous algorithm or insulin infusion algorithm 1A
Use maintenance IV fluids without dextrose (e.g. NS rather than D5W NS). If on subcutaneous insulin no additional IV
dextrose is required if the patient is not malnourished or in a severely catabolic state. If on an insulin drip, substrate must be
provided as constant dextrose infusion (e.g. D5W @ 10-40 ml/hr). 1C
Patient able to tolerate at least 50% of prescribed diet?
YES
Resume previous insulin regimen or
oral antidiabetes medication
(check serum creatinine before resuming metformin). 1C

NO
Continue IV or subcutaneous insulin
based on clinical judgment. 1C
Consider insulin infusion if blood glucose remains >180 mg/dl.
1B

Pre, Intra and Post-Operative Subcutaneous Short-Acting Insulin Algorithm

for Patients with Known Diabetes or Newly Discovered Hyperglycemia
Non-Critically Ill
This algorithm can be used:
To supplement an insulin regimen already in place
For patients previously on oral antidiabetes medications
For patients with hyperglycemia without a diagnosis of diabetes. For patients without a diagnosis of diabetes who are
normoglycemic prior to surgery, there is no evidence to support a specific frequency of monitoring glucose during surgery.
Certain major surgical procedures such as cardiovascular and transplant surgery are associated with hyperglycemia and warrant
frequent blood glucose monitoring during and after surgery.
Monitor glucose level and administer insulin: 1A
For glucose level >180 mg/dl, check hourly 1C; if no improvement in glycemic control, consider insulin dosing according to next
higher weight class. 1C (see chart below)
Every 4-6 hours if using regular insulin (short-acting) 1C
Every 2-4 hours if using aspart, glulisine, or lispro (rapid-acting) 1C
Weight Class I
(<175 lbs/80 kg)

Weight Class II
(175-220 lbs/81-99 kg)

Weight Class III

(>220 lbs/100 kg)

BG (mg/dl)

Insulin Units (subcut)

Insulin Units (subcut)

Insulin Units (subcut)

<180
181-200
201-250
>250

0 unit
1 unit
2 units
Begin insulin infusion

0 unit
2 units
4 units
Begin insulin infusion

0 units
4 units
6 units
Begin insulin infusion

Copyright 2009 by Joslin Diabetes Center. All rights reserved. Any reproduction of this document which omits Joslins name or copyright notice is prohibited.
This document may be reproduced for personal use only. It may not be distributed or sold. It may not be published in any other format without the prior, written
permission of Joslin Diabetes Center, Publications Department, 617-226-5815.

Pre, Intra and Post Operative IV Insulin Infusion Algorithm

Decision to initiate IV insulin:
If BG >180 mg/dl twice intra-operatively 1B
If BG >180 mg/dl twice postoperatively for cardiothoracic surgery 1B
If BG >180 mg/dl twice in intensive care units in non-cardiothoracic cases 1B
A number of well-validated insulin infusion protocols have been shown to work effectively. Two sample algorithms are provided
on pages 4 and 5: one designed to target BG levels of 100-180mg/dl for the non-critically ill patient, the other to target BG levels
of 140-180 mg/dl for the critically ill patient.

If BG <180 mg/dl, begin D5W at 40 ml/hr or D10W at 20 ml/hr. Maintenance IV fluids without dextrose (e.g. LR or NS or NS)
will be added to this in accordance with the patients volume requirements. For prevention of ketosis, in most individuals,
50g/24 hours of glucose is generally recommended 1C.
Calculating the Initial Insulin Dose
If BG >180 mg/dl, give stat dose of IV insulin, 0.1 units/kg body weight.
For patients having major surgery, larger starting doses can be given, and initiate an hourly rate of total daily dose of insulin
divided by 24.
For patients who have never been on insulin, begin with 0.02 units/kg body weight/hr.
For patients on total parenteral nutrition (TPN), insulin infusion is in addition to insulin currently administered in the TPN
solution.
Alternative Initial Dose
Blood glucose (mg/dl)
181-200
201-250
251-300
301-350
>350

Regular Insulin (bolus)

No Bolus
3 units IV
6 units IV
9 units IV
10 units IV

Regular Insulin (IV infusion per hour)

2 units
2 units
3 units
3 units
4 units

Check BG Hourly

See Infusion Algorithm pages 4 and 5

Copyright 2009 by Joslin Diabetes Center. All rights reserved. Any reproduction of this document which omits Joslins name or copyright notice is prohibited.
This document may be reproduced for personal use only. It may not be distributed or sold. It may not be published in any other format without the prior, written
permission of Joslin Diabetes Center, Publications Department, 617-226-5815.

Insulin Infusion Algorithm

for Critically Ill Intraoperative and Medical ICU Patients
(Target BG 140-180 mg/dl)
Insulin dose adjustments using this algorithm do not replace sound medical judgment.
<100
Current BG
level (mg/dl)
101-140

Hold drip and give - 1 amp 50% glucose and check BG every 30 minutes until >140 mg/dl and then
re-initiate drip at 50% previous rate
Previous Blood Glucose (mg/dl)
<100

100-140

rate by
1unit/hr

rate by 25% or
0.5 units/hr*

201-250

251-300

181-200

201-250

rate by 1 unit/hr

rate by 0.5 units/hr

rate by 25% or 2 units/hr*

rate by 33% or 2.5 units/hr*

301-400
>400

251-300

rate by 50% or 2 units/hr*

301-400

>400

rate by 75% or
2 units/hr*

rate by 50% or 2 units/hr*

No Change

141-180
181-200

141-180

rate by
25% or
1 unit/hr*

No Change

rate by 25% or 2 units/hr*

rate by 25% or 1 unit/hr*

rate by
rate by
25% or
rate by 1
25% or
unit/hr
1.5
1 unit/hr*
units/hr*
rate by 40% or 3 units/hr*
rate by 50% or 4 units/hr*

rate by
1.5
units/hr

rate by
1 unit/hr

No
Change

rate by
25% or
2 units/hr*

No
Change

*Whichever is greater change

This algorithm assumes hourly BG checks during insulin dose titration.

If BG in desirable range (140-180 mg/dl) for 4 hours, decrease frequency of BG checks to every 2 hours while BG stays in target.
If experiencing unexplained hypoglycemia or hyperglycemia, investigate and correct causative factors.
If there is any significant change in glycemic source (i.e., parenteral, enteral or oral intake), expect to make insulin adjustment.
Common reasons to discontinue insulin infusion:

Patient tolerating at least 50% of normal oral intake or enteral feedings

Clinically appropriate to transfer patient to a unit that does not do insulin infusions
Patient on stable regimen of TPN with most of insulin already in TPN solution

Two hours before discontinuing insulin infusion, initiate alternative glycemic management:

For patients with type 1 diabetes or those with type 2 diabetes previously controlled on insulin: If NPO, initiate basal
subcutaneous insulin (glargine, detemir or NPH) at 80% of the insulin administered over the previous 24 hours by insulin
infusion. If the patient is taking more than 50% of usual oral or enteral intake, give 50% of insulin dose as basal insulin based
on previous 24 hours of insulin infused or 0.25 units/kg and initiate pre-meal bolus and correction dose to maintain BG in target.
Another alternative is to resume pre-hospital insulin regimen. Insulin pump patients can resume pump use based on hospital
policy.
For patients with type 2 diabetes previously treated with oral antidiabetes agents: If patient had good diabetes control previous to
hospitalization, a return to oral agent therapy may be considered based on postoperative clinical status; if pre-hospital control was
inadequate, plan for discharge on subcutaneous insulin.
Copyright 2009 by Joslin Diabetes Center. All rights reserved. Any reproduction of this document which omits Joslins name or copyright notice is prohibited.
This document may be reproduced for personal use only. It may not be distributed or sold. It may not be published in any other format without the prior, written
permission of Joslin Diabetes Center, Publications Department, 617-226-5815.

Insulin Infusion Algorithm

for Non-Critically Ill Patients
(Target BG 100-180 mg/dl)
Insulin dose adjustments using this algorithm do not replace sound medical judgment.
Some evidence suggests a higher incidence of hypoglycemia using these lower glucose targets. There is disagreement among
experts about the degree of glycemic control needed to decrease morbidity and mortality while avoiding severe hypoglycemia.
< 100
Current
BG level
(mg/dl)

Hold drip and give 1 amp 50% glucose and check BG every 30 minutes until >100 mg/dl and then re-initiate
drip at 50% previous rate
Previous Blood Glucose (mg/dl)
< 100

100-140

rate by 1
unit/hr

rate by 0.5 units/hr

201-250

rate by 25% rate by

1.0
or 2 unit/hr* units/hr

251-300

rate by 25% or 2 units/hr*

301-350

rate by 33% or 2.5

units/hr*

351-399
> 400
*Whichever is greater change

181-200

201-250

rate by 0.5
units/hr

No change

100-180
181-200

141-180

251-300

rate by 50% or 2
units/hr*

>400

rate by 75% or
2 units/hr*

rate by 50% or 2 units/hr*

No change

No
change

rate by 0.5 unit/hr

rate by 25% or 1 unit/hr*
rate by
rate by
rate by
25% or 1.5 25% or
1 unit/hr
units/hr*
1 unit/hr*
rate by 40% or 3 units/hr*
rate by 50% or 4 units/hr*

301-400

rate by
1.5 units/hr

rate by 25% or
2 units/hr*
rate by
1 unit/hr

No
Change

rate by
25% or
2 units/hr*

No
Change

This algorithm assumes hourly BG checks during insulin dose titration.

If BG in desirable range (100-180 mg/dl) for 2-3 hours can decrease frequency of BG checks to every 2 hours while BG stays in
target.

If experiencing unexplained hypoglycemia or hyperglycemia, investigate and correct causative factors.

If there is any significant change in glycemic source (i.e., parenteral, enteral or oral intake), expect to make insulin adjustment.
Common reasons to discontinue insulin infusion:

Patient tolerating at least 50% of normal oral intake or enteral feedings

Clinically appropriate to transfer patient to a unit that does not do insulin infusions
Patient on stable regimen of TPN with most of insulin already in TPN solution

Two hours before discontinuing insulin infusion, initiate alternative glycemic management:

For patients with type 1 diabetes or those with type 2 diabetes previously controlled on insulin: If NPO, initiate basal
subcutaneous insulin (glargine, detemir or NPH) at 80% of the insulin administered over the previous 24 hours by insulin
infusion. If the patient is taking more than 50% of usual oral or enteral intake, give 50% of insulin dose as basal based on
previous 24 hours of insulin infused or 0.25 units/kg and initiate pre-meal bolus and correction dose to maintain BG in target.
Another alternative is to resume pre-hospital insulin regimen. Insulin pump patients can resume pump use based on hospital
policy.
For patients with type 2 diabetes previously treated with oral antidiabetes agents: If patient had good diabetes control previous to
hospitalization, a return to oral agent therapy may be considered based on postoperative clinical status; if pre-hospital control was
inadequate, plan for discharge on subcutaneous insulin.
Copyright 2009 by Joslin Diabetes Center. All rights reserved. Any reproduction of this document which omits Joslins name or copyright notice is prohibited.
This document may be reproduced for personal use only. It may not be distributed or sold. It may not be published in any other format without the prior, written
permission of Joslin Diabetes Center, Publications Department, 617-226-5815.

Glossary
AACE American Association of Clinical Endocrinologists

ICU Intensive care unit

NS Normal saline

ADA- American Diabetes Association

IV Intravenous

BG Blood glucose

LE Lower extremity

Subcut - subcutaneously

CSII - continuous subcutaneous insulin infusion

LR Lactated Ringers

TPN Total parenteral nutrition

DM Diabetes mellitus

NPO Nothing by mouth

Approved by Clinical Oversight Committee on 10/23/09

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Copyright 2009 by Joslin Diabetes Center. All rights reserved. Any reproduction of this document which omits Joslins name or copyright notice is prohibited.
This document may be reproduced for personal use only. It may not be distributed or sold. It may not be published in any other format without the prior, written
permission of Joslin Diabetes Center, Publications Department, 617-226-5815.

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Copyright 2009 by Joslin Diabetes Center. All rights reserved. Any reproduction of this document which omits Joslins name or copyright notice is prohibited.
This document may be reproduced for personal use only. It may not be distributed or sold. It may not be published in any other format without the prior, written
permission of Joslin Diabetes Center, Publications Department, 617-226-5815.

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JOSLIN CLINICAL OVERSIGHT COMMITTEE

Om Ganda, MD, Chairperson

David Feinbloom, MD

Susan Sjostrom, JD

Richard Beaser, MD

Richard Jackson, MD

Kenneth Snow, MD

Elizabeth Blair, MS, ANP-BC, CDE

Lori Laffel, MD, MPH

Robert Stanton, MD

Patty Bonsignore, MS, RN, CDE

Melinda Maryniuk, MEd, RD, CDE

William Sullivan, MD

Amy Campbell, MS, RD, CDE

Medha Munshi, MD

Howard Wolpert, MD

Catherine Carver, MS, ANP-BC, CDE

Jo-Anne Rizzotto, MEd, RD, CDE

Martin Abrahamson, MD (ex officio)

Jerry Cavallerano, OD, PhD

Kristi Silver, MD

Copyright 2009 by Joslin Diabetes Center. All rights reserved. Any reproduction of this document which omits Joslins name or copyright notice is prohibited.
This document may be reproduced for personal use only. It may not be distributed or sold. It may not be published in any other format without the prior, written
permission of Joslin Diabetes Center, Publications Department, 617-226-5815.