Unique Plan Description: Peri op Diabetic Management AM Admit OR before 12nn(MH WH FH)
Plan Selection Display: Peri op Diabetic Management AM Admit OR before 12nn(MH WH FH)
PlanType: Medical                                 
Version: 1          
Begin Effective Date: 2016-01-27 14:18:08
End Effective Date: 2100-12-31 00:00:00
Last Updated Date: 2021-12-21 10:43:57
Available at all facilities: No

Peri op Diabetic Management AM Admit OR before 12n
Laboratory
	Glucose POC - RN
		T;N, Q2H-Sch, POC glucose to be done upon arrival to preop, upon arrival to PACU and q2h during preop, intra op and PACU stay
IV Solutions
	Dextrose 5% in Water
		1,000 mL, IV, 125 ml/hr
			Comment: 125 ml/hr in  preop if POC glucose <100mg/dL
Medications
		NOTE:   Consider IV insulin infusion protocol if procedure >3 hr, or NPO expected 1-2 days postop(NOTE)*
		NOTE:    For patients receiving morning only dose of insulin & no insulin received the evening/bedtime prior day(NOTE)*
	Levemir
		Solution, SUBCUTANEOUS, Once, T;N
			Comment: at bedtime night prior to day of surgery.  Recommend 70% of usual dose
	Standard Dose Regular
		2-12, units, Injection, SUBCUTANEOUS, Q6H-Sch, PRN, sliding scale, Routine
			Comment: Under 150, Do not give any insulin. 150 - 199 = 2 units, 200 - 249 = 4 units, 250 - 299 = 6 units, 300 - 349 = 8 units ,350 - 399 = 10 units. Over 399 = 12 units
	Standard Dose NovoLOG
		2-12, units, Injection, SUBCUTANEOUS, Q6H-Sch, PRN, sliding scale, Routine
			Comment: Under 150, Do not give any insulin. 150 - 199 = 2 units, 200 - 249 = 4 units, 250 - 299 = 6 units, 300 - 349 = 8 units, 350 - 399 = 10 units. Over 399 = 12 units
Patient Care
	Notify MD
		T;N, with Preop POC glucose result for further orders.
	Glucose Management
		T;N, If on insulin pump and to receive general anesthesia, initiate IV insulin infusion protocol at basal infusion rate of the SC pump and titrate per protocol. Patient to disconnect SC insulin pump when IV insulin drip is initiated.

Hypoglycemia Protocol
Laboratory
	Glucose POC - RN
		T;N, 15 minutes after carbohydrate source or medication administered
	Order Lab
		T;N, Blood Glucose (POC) as needed for signs and symptoms of hypoglycemia for patients with diabetic medication orders or known diabetic.
	Hemoglobin A1C
		T+1;0400, Routine, spec type = Blood
Medications
	glucose oral gel (JE)
		15 gm, Gel, By Mouth, Q15MIN, PRN for see comment
			Comment: : for blood glucose 60-70mg/dL as an alternative to apple juice. Notify provider if given with corresponding POC glucose re-check value.
	Dextrose 50%
		25 mL, Injection, IV PUSH, Q15MIN, PRN for low blood sugar, Routine
			Comment: Give if blood glucose less than 60mg/dL or 60-70 mg/dL and patient unable to tolerate oral intake. Notify provider if given with corresponding POC glucose recheck value.
	glucagon
		1 mg, Injection, IV Push, Q15MIN, PRN for low blood sugar, Routine, T;N
			Comment: Give if blood glucose < 70mg/dL AND if dextrose 50% injectable unavailable OR inadequate response to IV dextrose 50%. May give SubQ or IM if patient does not have IV access. Notify provider if given with corresponding POC glucose recheck value.
Patient Care
	IV-Maintain
		T;N
			Comment: Patient should have IV site while on hypoglycemia protocol
	Hypoglycemia Treatment Parameters
		T;N, Hypoglycemia protocol initiated for patients with glucose <70mg/dl. Patient should have an IV while in Hypoglycemia protocol.
		T;N, glucose <60 mg/dL treat with Dextrose 50% 25 mL OR glucagon 1mg as per medication orders. Notify provider as per critical result protocol.
			Comment: Repeat treatment as outlined in hypoglycemia parameters. Notify provider of all treatments given and POC glucose recheck values. When notifying provider of hypoglycemic treatment, clarify with provider future instructions on diabetic medication therapy.
		T;N, glucose 60-70 mg/dL, administer 4 oz apple juice, 4 oz non-diet soda, or glucose gel (MJE/MFH).  If patient NPO or unable to tolerate oral intake, give Dextrose 50% 25 mL OR glucagon 1mg as per medication orders.
			Comment: Repeat treatment as outlined in hypoglycemia parameters. Notify provider of all treatments given and POC glucose recheck values. When notifying provider of hypoglycemic treatment, clarify with provider future instructions on diabetic medication therapy.
		T;N, After initial treatment of any glucose value </= 70 mg/dL, repeat POC glucose in 15 min; if result </= 70mg/dL continue treating as per protocol and rechecking glucose 15 min after treatment until glucose >70mg/dL.
			Comment: Notify provider of all treatments given and corresponding POC glucose recheck values. When notifying provider of hypoglycemic treatment, clarify with provider future instructions on diabetic medication therapy.
		T;N, Once glucose is within normal limits, give 1 complex carb and 1 protein source (such as ½ sandwich OR 1 individual container of peanut butter and 3 packs of crackers) or patient meal if patient able to take orals to prevent recurrent hypoglycemia.
			Comment: When notifying provider of hypoglycemic treatment, clarify with provider future instructions on diabetic medication therapy.
	Communication to HOSPITAL RN
		T;N, When notifying provider of hypoglycemic treatment, clarify with provider future instructions on diabetic medication therapy.

Insulin Drip (IV Infusion) Protocol
Laboratory
	Glucose POC - RN
		T;N, Q1H
		T;N, As needed for signs and symptoms of hypoglycemia
IV Solutions
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	insulin regular 100 units/NS 100 mL Premix
		100 units, EVERY BAG, 2 units/hr
		100 mL, IV, Routine, T;N, Total Volume = 100
			Comment: Concentration: 1 unit/mL, Initial rate based on initial glucose:  181-300: 2 units/hr;  301-400:  3 units/hr; 401 or greater: 4 units/hr;   Titrate infusion to target glucose of 140-180: If glucose is:1) Less than 100 discontinue infusion, ,continue blood glucose monitoring and follow Insulin IV infusion hypoglycemia treatment parameters if necessary; restart drip at 1/2 previous rate when glucose >120.2) 100-120, decrease infusion by 1 unit/hr3) 121-139,decrease rate by 0.5unit/hr4) 140-180 , no change5) 181-249, and is greater than or equal to the previous glucose, increase infusion by 0.5 unit/hr6) 181-249, and is less than the previous glucose, maintain same rate7) 250-350, increase infusion by 1 unit/hr8) > 351, increase infusion by 2 unit/hr. Contact MD if rate >10 unit/hr.  If the glucose decreases >75mg/dl from the last glucose check, decrease insulin rate by 50% and check blood glucose in 30 minutes. If enteral and/or parenteral nutrition support is stopped or held, decrease infusion to 0.5 unit/hour and notify physician
	Dextrose 5% with 0.45% NaCl
		1,000 mL, IV, Routine, 50 ml/hr, Total Volume = 1,000
			Comment: Begin if patient not currently on dextrose containing IV or TPN when glucose is 200 or less.  If patient has a current IV order that doesn't contain dextrose, add dextrose to that IV and do not start this D5/45 Order.
Medications
	insulin regular
		5 units, Solution-Injection, IV Push, Once, PRN see comment
			Comment: Prior to starting insulin drip if initial blood glucose 301 or greater
	Dextrose 50% injection
		25 mL, Injection, IV Push, Q15MIN, PRN low blood sugar, Routine
			Comment: Give if blood glucose less than 60mg/dL or 60-70 mg/dL and patient unable to tolerate oral intake. Notify provider if given with corresponding POC glucose recheck value.
		50 mL, Injection, IV Push, Q15MIN, PRN low blood sugar, Routine
			Comment: Give if blood glucose less than 60mg/dL or 60-70 mg/dL and patient unable to tolerate oral intake. Notify provider if given with corresponding POC glucose recheck value.
	Dextrose 10% in Water (FH)
		250 mL, Injection, IVPB, Q30MIN, PRN low blood sugar, infuse over 30 min(s)
			Comment: Give if blood glucose less than 60mg/dL or 60-70 mg/dL and patient unable to tolerate oral intake. Notify provider if given with corresponding POC glucose recheck value.
	glucagon
		1 mg, Injection, IV Push, Q15MIN, PRN low blood sugar, Routine, T;N
			Comment: Give if blood glucose < 70mg/dL AND if dextrose 50% injectable unavailable OR inadequate response to IV dextrose 50%. May give SubQ or IM if patient does not have IV access. Notify provider if given with corresponding POC glucose recheck value.
Patient Care
	Notify MD
		T;N, for instructions if dietary change: abrupt change in oral intake, change to NPO status, tube feedings are held or discontinued, TPN held or discontinued.  (caloric intake necessary to prevent hypoglycemia)
		T;N, If insulin requirements > 10units/hr for further instruction
	Notify MD of Lab results
		T;N, if blood glucose is not less than 180 after 6 hours on the Insulin IV Infusion protocol.
	IV Insulin Parameters
		T;N, Decrease infusion to 0.5 units/hour if enteral and/or parenteral nutrition support is stopped or held and notify physician.
		T;N, If the glucose decreases >75mg/dl from the last glucose check, decrease insulin rate by 50% and check blood glucose in 30 minutes.
		T;N, If initial glucose < 180, do not start infusion.  Enter order for blood glucose Q4H and start infusion if necessary based on parameters.
		T;N, When glucose </= 200, and patient not on a dextrose containing IV/TPN: add D5W to current IV.  Continue same IV base, electrolytes and rate.  If patient not currently on IV or TPN, initiate D5W/0.45% sodium chloride.
		T;N, Stop insulin infusion 2 hours after administration of antidiabetic medication ordered for transition from IV infusion (long-acting insulin, etc.)
	Order Lab
		When glucose is in target range (140-180) for 6 hours, cancel glucose Q1H order and enter new glucose order Q2H.  If glucose falls out of target range, change glucose checks back to Q1H until in range again for 6 hours.
	Hypoglycemia Treatment Parameters
		T;N, When blood glucose is greater than 120 mg/dL, restart infusion at 1/2 previous rate and change glucose checks to every hour until glucose is in the target range (140-180) for 6 hours, then may change to Q2H glucose checks.
		T;N, Hypoglycemia protocol initiated for patients with glucose <70mg/dl.  Patient should have an IV while on insulin protocol.
		T;N, glucose <60 mg/dL, discontinue infusion and treat with Dextrose 50% 25 mL OR glucagon 1mg as per medication orders. Notify provider as per critical result protocol.
			Comment: Repeat treatment as outlined in hypoglycemia parameters. Notify provider of all treatments given and POC glucose recheck values. When notifying provider of hypoglycemic treatment, clarify with provider future instructions on diabetic medication therapy
		T;N, glucose 60-70 mg/dL, discontinue infusion, and administer 4 oz apple juice, 4 oz non-diet soda, or glucose gel.  If patient NPO or unable to tolerate oral intake, give Dextrose 50% 25 mL OR glucagon 1mg as per medication orders.
			Comment: Repeat treatment as outlined in hypoglycemia parameters. Notify provider of all treatments given and POC glucose recheck values. When notifying provider of hypoglycemic treatment, clarify with provider future instructions on diabetic medication therapy.
		T;N, After initial treatment of any glucose value </= 70 mg/dL, repeat POC glucose in 15 min; if result </= 70mg/dL continue treating as per protocol and rechecking glucose 15 min after treatment until glucose >70mg/dL.
			Comment: Notify provider of all treatments given and corresponding POC glucose recheck values. When notifying provider of hypoglycemic treatment, clarify with provider future instructions on diabetic medication therapy.
		T;N, If the patient has a diet ordered and Once glucose is within normal limits, give 1 complex carb and 1 protein source.
			Comment: (such as ½ sandwich OR 1 individual container of peanut butter and 3 packs of crackers) or patient meal if patient able to take orals to prevent recurrent hypoglycemia.When notifying provider of hypoglycemic treatment, clarify with provider future instructions on diabetic medication therapy.

*Report Legend:
DEF - This order sentence is the default for the selected order
GOAL - This component is a goal
IND - This component is an indicator
INT - This component is an intervention
IVS - This component is an IV Set
NOTE - This component is a note
Rx - This component is a prescription
SUB - This component is a sub phase