Emory University School of Medicine
Emory University School of Medicine
Department of Anesthesiology

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Department of Anesthesiology

Insulin Titration

EHC Perioperative Insulin Guidelines

  1. All diabetic patients should have BG checked at least once between 2 hours preoperatively until handoff in the PACU.
  2. Any BG > 180mg/dl should be treated with either SQ insulin (lispro) or IV insulin infusion within 30 minutes of the results posting. 
  3. When BG treatment is required intraoperatively, please recheck BG every 2hrs. Wait a minimum of 2 hours after SQ insulin before administering additional insulin. 

SQ Insulin and Starting Rate for Insulin Infusions
Blood Glucose Insulin Sensitive2 Usual Insulin Insulin Resistent3
141-180 0 2 3
181-220 2 3 4
221-260 3 4 5
261-300 4 6 8
301-350 5 8 10
351-400 6 10 12
>400 8 12 14

Note:

1) Consider Insulin Infusion for any BG>300
2) Insulin Sensitive: Age >70, GFR <45 ml/min.  No history of diabetes
3) Insulin Resistant: BMI >35, Home insulin >80U/day, Steroids > 20 mg Prednisone daily

Insulin Infusion
Change from prior BG Check Change from prior BG Check Change from prior BG Check
Blood Glucose Increase >30 mg/dL Decrease 0-30 mg/DL Decrease >30 mg/dL
<70 Hold Drip and administer D50 Hold Drip and administer D50 Hold Drip and administer D50
70-100 Hold insulin drip.  Check BG q30m until BG is >110 mg/dL.  Check BG q1h thereafter Hold insulin drip.  Check BG q30m until BG is >110 mg/dL. Check BG q1h thereafter Hold insulin drip.  Check BG q30m until BG is >110 mg/dL. Check BG q1h thereafter
101-109 Decrease rate by 1/2 Decrease rate by 1/2 1. Hold insulin drip
2. Check BG q1h. Restart when BG >180
110-140 No Change No Change Decrease rate by 1/2
141-180 No Change No Change No Change
181-210 Increase rate by 1 unit/hr Increase rate by 1 unit/hr No Change
211-240 Increase rate by 2 units/hr Increase rate by 2 units/hr No Change
>241 Increase rate by 3 units/hr Increase rate by 3 units/hr No Change

D50 Protocol

  1. Hold insulin drip
  2. BG 41-70: Give 1/3 amp D50 IV
  3. BG ≤ 40: Give 1 amp D50 IV
  4. Repeat BG q15m until BG >70 mg/dL.  Check q30 until BG >110 mg/dL
  5. Once BG >110 mg/dL, check BG hourly and restart infusion at 1/2 prior rate once BG >180 mg/dL