Diabetes, whether diagnosed or undiagnosed, is often a comorbidity requiring care during hospitalization and is a major concern in the surgical population. A large number of patients admitted for surgical problems have diabetes.1 The goal of care for these patients is to maintain blood glucose levels between 140 mg/dL and 180 mg/dL, based on recommendations set by the American Diabetes Association (ADA) in 2015. However, elevated blood glucose levels, which can result in postoperative infections, extended hospital stays, readmissions, and death, continue to be a problem in the care of these patients.


Studies have shown that hyperglycemia and poorly managed blood glucose levels occurred in 25% to 42% of surgical patients2 with sustained blood glucose levels of 180 mg/dL to greater than 200 mg/dL. 


Hyperglycemia in surgical patients is an independent predictor of perioperative complications and can lead to death. The first and second postoperative days carry the highest risk for elevated blood glucose. These 2 days are the greatest predictors of serious infection and postoperative complications.3

Prescribing basal insulin instead of sliding-scale insulin coverage in the surgical inpatient setting has been shown to decrease postoperative complications and length of hospital stay. The 2015 ADA guidelines support prescribing basal insulin for inpatient blood glucose management and discourage the use of sliding-scale insulin therapy and oral agents for glucose management in hospitalized patients. Oral agents lack efficacy in the inpatient setting and are associated with multiple side effects. They also offer a slow onset of action and do not allow for rapid glycemic control or dose adjustments to meet the needs of acutely ill patients. The use of standardized order sets with generalized guidelines for insulin needs, management of hypoglycemia, and regimen modifications is the best method for implementation. 


One concern surrounding the use of basal insulin is hypoglycemia. However, basal insulin best mimics the body’s own insulin secretion and, as a result, has a low incidence of hypoglycemia. 


Basal insulin should be continued without regard to a patient’s ability to take food or fluids by mouth. Continuing basal insulin improves mean daily blood glucose without increasing hypoglycemic episodes.4 Standardized order sets should include general guidelines for insulin adjustments for patients undergoing procedures and for those who can take nothing by mouth for prolonged periods, and guidelines for management of hypoglycemia. Insulin should be adjusted daily as needed based on the previous day’s blood glucose measurements. These measurements should be taken before meals and at bedtime for patients taking oral nutrition, or every 4 to 6 hours for patients who can take nothing by mouth. 


The use of basal insulin with or without nutritional correction is the best approach to blood glucose management for noncritically ill surgical patients. This approach improves overall blood glucose and, thereby, improves outcomes by decreasing length of hospital stay, postoperative complications, and long-term complications associated with poor blood glucose control. Basal insulin best mimics the body’s own insulin secretion, and evidence shows that its use does not result in an increase in hypoglycemic episodes.

Jennifer Schomaker, DNP, APRN-BC, FNP, ACNS, is a nurse practitioner at Hennepin County Medical Center in Minneapolis, Minn. Sharon Fruh, PhD, RN, FNP-BC, is a professor at the University of South Alabama College of Nursing in Mobile, Ala.

References

  1. Crawford K. Crit Care Nurs Clin North Am. 2013;25[1]:1-6
  2. Coan KE, et al. J Diabetes Sci Technol. 2013;7[4]:880-887
  3. Moghissi ES. Am J Health Syst Pharm. 2010;67[suppl 8]:S3-S8
  4. Harbin M, Dossa A, de Lemos J, et al. Can J Diabetes. 2015;39[3]:210-215