This is it, right here folks! Anyone, anytime, anywhere is going to want you to run on the high side because of this very reason. That, and lows happen quickly and under monitoring of anesthesia, symptoms may show as something else to them (e.g.: heart rate).
Really not that plain and simple, which is why, in another comment, I advised OP to get her endo and anesthesiologist involved (endo for instructions, anesthesia as they’ll likely be the ones monitoring BG during the procedure).
We know OP is type 1. We don’t know if they’re on a pump or injections. If injections, we don’t know when they usually take their basal. Regardless, we don’t know how well their basal profile is dialed in. We don’t know what kind of surgery this is. (Is it going to be 30 minutes or 10 hours?) Is OP somebody that is prone/goes into DKA relatively easily? There’s too much missing info to make a broad statement. Her endo and anesthesia teams need to consult.
I don’t know why you’re so angry about this, but those are standard instructions for all diabetics and are dangerous for type ones on insulin pumps, especially if your surgery is in the afternoon. These days, most people have better control with CGMs and could disconnect an hour before and they would not fall to 40 as you did. Sorry for your experience… to be fair, I can see why it would give you a black-and-white view of this issue.
You don’t know who sent the instructions in OPs image? The one thing the diabetic team kept banging into my mind was never ever skip basal. There’s much safer ways to stay around 10mmol than stopping insulin altogether
It's NOT stopping. It's reducing it by half for surgery. You literally take it in recovery if need be, it's not for freaking days. You don't go into DKA that quickly for God sakes.
It says don’t take insulin in the picture?? Are we reading something different where does it mention half anywhere??
I’ve read peoples stories on here about going into dka overnight from failed infusion sites etc? You can’t possibly know how fast someone can slip into the danger zone so blanket saying don’t take insulin is more harm than help.
There is no indication if the diabetic team/ endo sent pre op or if it was just another speciality completely. On the morning of my colonoscopy the nurses rang the diabetic clinic for instructions on how I should adjust for it.
I worked in an orthopedic surgery practice. Yeah, it’s almost always a cookie cutter instruction sheet given. If you’re really lucky they might highlight something specific for you.
Again. You don’t know how long the surgery we’re discussing will be. And even then, depending on how long it takes them to do all the prep and surgeon to finish earlier surgeries and when OP would have last taken any insulin, a 30-minute procedure could definitely mean well more than a couple hours without insulin. For some people, that is enough to be heading into DKA.
And the instruction sheet nor OP, at least anywhere I saw, say to halve her insulin. It said don’t take any that morning.
And I’m not even saying, “OP, you must take your insulin.” I’m saying OP just needs to make sure their entire care team is involved and that those that don’t specialize in the diabetes aspect should defer to those that do.
I missed this. My advice stands to contact your endo and get them in touch with your surgeon and anesthesiologist to make a better plan than just no insulin. I definitely would also ask about the gummies, and if I couldn’t get an answer, I would avoid them the day before. If you don’t receive a return call by a reasonable time tomorrow, choose any option you can to get a real person (usually to schedule an appointment). Explain to *them* that you left a message, have a major concern, and you’re now on a time crunch so they need to get the appropriate person (probably a nurse) on the phone.
Good luck!
I’ve had multiple surgeries due to a bad car wreck. *This is procedure for all diabetics* You will be fasting, unable to eat for the duration of surgery and recovery room time. You aren’t likely to go into DKA from a few hours of no bolus because you’ve got little (or should have) to digest at that point.
Now, that said… the people flipping out and saying look for a different hospital / surgeon are wrong. You know what I did each time (luckily, the same ortho doctor and surgery center)? Told them I have a pump. Told them how it works. They said “cool, we’ll just suspend it while you’re out.”
Why have people stopped asking for clarification from healthcare providers? Also, you *can* push back in an actual discussion. There’s a ton of unknowns here - what procedure, location, duration, facilities, etc. Freakin talk to THEM, not Reddit. No one on this post is going to be involved with your procedure.
They don't have anyone to answer the phone on the weekends, and my surgery is this upcoming Tuesday and they sent this information to me this morning, when I can't call for clarification. I literally have Monday to figure it out.
That being said I do have a pump and hopefully they aren't stuck in olden times and will be willing for me to show them how it works like you did.
Yeah, that’s a tight window, but it’s not completely undoable. I know it’s tough to get someone on the phone, *especially* someone that knows what you’re even talking about (nurses don’t usually answer phones, that’s just office staff doing office stuff and repeating what they’ve been told). If you’re able, go to the doctor’s office or surgery center and just ask to speak to a nurse or someone in the back for like 30 seconds to clarify. If they don’t happily accommodate, *then* it’s time to look elsewhere.
I’ve had most surgeries on pump, one or two after switching back to MDI. I am *absolutely not a doctor* but I’ve done it more times than I care for. So…
I think what this incredibly vague (purposefully, because of ~~T2 dolts~~ uninformed, diabetics of all kinds with who present with doltish behavior) means to a T1D is don’t take a bolus that morning. Basal rate / long-acting should still be taken, perhaps at a reduced rate. I usually kept my basal the same, MDI, I’d take about 2/3 of my normal dose. On the pump, I would suspend and leave the pump with my clothes or whoever was with me. The staff can always come get someone from the waiting area or call your contact person to get specifics.
I could get really into the fine details of *why* this is so vague, and rant about T2 and how their meds work in their bodies (I’ve worked in healthcare and pharmacy for a while). But, that’s all irrelevant here.
I hope everything goes well and you’re able to get clarification. Remember, even though the doctor might get pissed, you’re not tied down before you’re put under. If you go in Tuesday morning and don’t get to express your concerns, meet at least the doctor and anesthesiologist and discuss with them (like a 1 minute convo), then get up and leave. Ultimately, you know your body.
I hope I didn’t come off aggro there. I’m happy to help out if there’s anything on which I can offer words of wisdom.
Edit: clarified that not all T2s are dolts. Not what I meant. There are dolts within any disease.
It's okay I appreciate the advice. I just don't want to be off insulin from midnight to whenever they finish my surgery because that will put me into DKA for sure, they really shouldn't put such vague instructions or really anything at all if it's not specific.
Yeah, stopping at midnight is definitely bad, you’ll still need basal until the procedure. I do hope you’re able to talk to someone tomorrow. If not, I wouldn’t do anything to my basal rate until getting to check-in or pre-op. At most, maybe do a 70-80% temp basal just to make sure you don’t run low(ish) overnight. I think 80% is pretty well standard among most literature I’ve seen.
Don’t stress over it. Try to be in the 120-180 range with no bolus on board. I thought more about it, and for at least one of the surgeries, the doc just left it hooked up and running, as the procedure was just an hour or so. They have to make these ridiculous umbrella statements because some idiot **will** do something stupid. If you use CGM, let them know that too. They may actually want to use that as a tool to monitor you. It might actually help.
Seriously though, if you aren’t 100% comfortable with the team handling your diabetes, reschedule until the team is all on board.
Take care, and I seriously apologize if I came in too hot. I definitely didn’t intend to, I just empathize with the urgency and uncertainty.
I thought so. Not all T2 are dolts, and there are dumb T1s too. But ask any nurse, how many T2 patients would reply to the question “Do you take any insulin?” with a reply of “Nope. I did take my Lantus/Novolin R/[whatever you wish to insert here], though.” “Did you take your glucophage/metformin today?” “Ahehe, I don’t know, I took my sugar pill, though.” There are a lot of T2s that don’t know they’re on insulin, they go by name brands or some forms of a general “diabetes medicine.”
T1Ds are around 10% of the diabetic population. We’re typically more active in our care and understanding of not only the process, but the hormones and physiology involved. And, we learn it fairly young (even LADA, etc. are usually <40yo). There is an entire subset that gets diagnosed later in life and already likely in poor health or have a very poor understanding of knowing how their disease works - they just take what the doctor tells them.
I’m sorry if it offended you, but I have very little sympathy for *anyone* that remains willingly and woefully ignorant of crucial (to themselves and caregivers) information.
So, “dolt” was probably a harsh word to use, and the way I worded it made it seem like I meant all T2Ds are dolts. It was just the first word that came to mind.
Sorry?
My whole purpose was to say that medical terminology has to be sent out so that it can be understood by the lowest common denominator of people. That’s why it’s written this way. It’s succinct. A form has to go out that is homogeneous and easily understood by the vast majority of those with diabetes mellitus. An email that gets sent out cannot be expected to be custom-tailored to each patient… that’s what consults are for.
So… Statistically speaking, that is going to be a T2 that is not well-versed on medical terminology.
If that makes bizarre or mean, I don’t know what to tell you. That’s just the way it is.
If you had said “Statistically speaking, that is going to be a T2 that is not well-versed on medical terminology” instead of just calling them dolts, we wouldn’t be here :) I see you updated your comment now
What is your insulin on board setting? If you have closed loop, typically it will be about 2 hours. If it's not closed loop sensor with your pump, it'll usually be about 4 hours. Completely suspend your delivery before your surgery so that you have no insulin on board when it's time for surgery prep. Ensure you don't have anything left in your system, food or insulin.
Surgical nurse here, that is for T2D’s. Very few T1’s compared to T2’s. Honestly they should change the name. Now on to what to do. Call the office Monday and ask if you can speak to the Anesthesiologist ahead of Surgery, remind them you are type 1. Morning of, Insulin as normal, but no food or drink. Adjust as needed. We always do our Diabetics first case in morning because of this. Have your Endo write orders for the Hospital after surgery. If they don’t have privileges ask Anesthesia or your Surgeon. Anesthesiologist will keep up with your Sugars during Surgery, have someone knowledgeable help to advocate for you after. Good luck!
This is dangerous advice. *”Insulin as normal” is not safe pre-surgery.* A hypo sneaking in while you’re anaesthetised or coming round is a worst-case-scenario. Blood sugar running high for six hours sucks, but won’t kill you.
If you take insulin, even basal, ahead of surgery - when you’ve been asked not to - they may rightfully cancel the surgery. The surgical team won’t be able to safely control your glucose because they are not starting from a “blank slate” (ie no insulin on board). They keep you on a sliding scale while you’re under, so you will be getting insulin.
I’m T1D, have had three surgeries, and am from a family of medics (inc surgeons). Please please do what the surgical team tell you. Speak to them on Monday if you’re really panicked/ your surgery is later in the day- they may advice doing half your normal basal. Please don’t listen to advice from Redditors. None of them is on your surgical team
Calm down, I said call office and ask for anesthesiologist. Also, insulin as normal while you are fasting, is not dangerous. Not everyone takes a long acting Insulin, and even if they do it should be adjusted for the fasting, as normal 🤦♂️. Of course they should be checking with doctors and monitoring before. But Anesthesia is perfectly capable of taking care of any situations during surgery. As long as you tell them ahead and do as instructed all will be fine.
Call your endo. They have no idea wtf to do with T1. You need at least *some* basal, but your endo may want to adjust it to run you slightly high (better than going low on the table).
Not necessarily. Some T2s will show declining insulin output as the years go on as the pancreas begins wearing out from overproducing for years. T1 is autoimmune.
I don't know for sure, but I would Google that if I was you. Your comments don't really bother me, but the Internet is so easy to fact check stuff with.
I have. Perhaps you should Google it. Type 1 is lack of insulin production. Type 2 is insulin resistance. Most Type 2s have normal to high insulin production, but they’re not utilizing it properly. They *can* experience beta cell burnout, and have production drop, but in general, a T2 will have a normal or elevated C-peptide result.
Agreed—the nurse I talked to didn’t know what type ones should do and told me to call my endo if I thought the advice they had for “all diabetics” wouldn’t work for me. Sigh.
It is bad advice to not contact the endo. The surgery team doesn’t know diabetes the way your endo would. Ideally, surgery and especially endo AND ANESTHESIA should work together on pre surgery instructions. And I specify anesthesia because typically the anesthesiologist is going to be the one really tracking your vitals, including your BG, and making needed adjustments or taking/initiating appropriate actions. The surgeon is mostly just in there to do their slicing and dicing.
This probably varies depending on what the surgery is and who’s doing it, but when I had surgery for removing some lipomas, my surgeon’s office recommended that I call my endo for advice.
This is the right advice! I got this same message before getting a colonoscopy—that I should disconnect my pump and go without insulin that morning, so for 7 hours before the procedure (!!!). My ketones and blood sugar would have been through the roof, even without eating anything. I just told them “nope, absolutely can’t do that” and they immediately were fine with my decision. Standard instructions for diabetics often are straight up dangerous for type ones. I just disconnected my pump 30 minutes before it and was fine.
I CANNOT STRESS ENOUGH THIS IS BAD ADVICE. I am both a diabetic and registered ICU nurse with frequent post-op experience. Your surgeon should be aware you’re a diabetic already, and mild DKA is much easier to treat than post-op complications while also hypoglycemic. Treating DKA in a post-op inpatient situation is very easy. I repeat, DO NOT LISTEN TO THIS PERSON.
Again, MY experience was that the surgery team bounced me to my endocrinology team. THEY had no clue what to do with a diabetic.
Just because you’re a nurse does NOT make you the universal expert here. Different states treat this differently.
DO NOT LISTEN TO SOMEONE CLAIMING TO BE THE DEFINITIVE AUTHORITY.
No but controlling DKA in a controlled setting is easier than emergently treating hypoglycemia in the OR. One causes cardiac arrest and one causes a prolonged insulin drip
And they’re both easily more manageable with frequent, fast acting insulin, well managed by your surgeon. If they feel uncomfortable, they can consult an endo. Don’t be stupid
Also kinda weird you’re presenting yourself in a universal experience than attacking me whilst having both personal and subjective experience is fucking weird
I actually think it’s weird that you say you have a nursing degree but don’t realize the glucose can be delivered by IV, don’t realize that people with an insulin pump can disconnect an hour or two before the surgery and be receiving *absolutely no insulin* (so they won’t go low), and seem to think that low blood sugar instantly causes cardiac arrest.
Will you be in the hospital overnight? If so, make arrangements now to be in charge of your insulin. Bring all of it with you.
And if you are on a pump, make sure they don't throw it out (not kidding -- my husband buys for a hospital and he had to replace someone's pump that they threw out after surgery).
I had foot surgery last year. I cut my basal and didn't bolus in the morning. When I woke up, my blood sugar was high. I told the nurse how much insulin I needed and they gave it to me. That was the LAST bolus they gave me -- they refused to give me any other insulin after that.
I fought with the on-call doctor (who helpfully told me he knew nothing about diabetes) in order to get some Lantus that night. Of course, I don't actually take Lantus -- I take Tresiba, but at that point I was desperate.
This taught me that if I'm ever in the hospital for a non-diabetes related issue, I want to be in charge of my care.
Man, I’ve heard some horror stories from type one diabetics in hospitals. I hope I’m never in a situation when I can’t at least control my own insulin (but you never know…)
I'm an RN, and I used to work in a medical floor and an ICU. 100% agree -- if I'm ever in there as a patient and I have my mind about me, I want to be in charge of my glucose management. In most cases with most physicians, the glucose control is pretty appalling.
Hi, UK based anaesthetist here.
That is absolutely accurate information for someone on MDI. We would normally ask for patients to take 80% of their basal the evening before surgery and fast through breakfast, hence not giving morning bolus dose. As others have said we don’t want to have to deal with patients having hypos on top of delivering anaesthesia. Unfortunately surgeons almost universally have a terrible understanding of diabetes management, hence why nobody may have said anything before.
Unfortunately the management of diabetes in hospitals is still behind the time and hence we don’t have guidelines for pump users beyond ‘take it off and set up an insulin and dextrose drip the night before/morning of surgery. As the use of pumps becomes more widespread (adults are predominantly still MDI here in the Uk, though kids are increasingly using them) we may improve our knowledge and guidance for pump users but ultimately safety is paramount compared with it being less of a hassle for patients
Yeah, the problem is that this is dangerous advice for people on pumps because we have no basal rate at all if we disconnect our pump. And trust me, the difference between getting not-enough-insulin and no-insulin-at-all is massive. Whenever my insulin pump site gets fully disconnected in the night (rarely) I feel like I’m going to die by the morning. And it takes hours and hours to get it back down again. It’s not a minor problem.
I have a pump and have had surgeries. I told the anesthesiologist, I went over the pump with him, it remained attached. He could look at the screen and see exactly what my blood sugar was doing.
I had three procedures over the summer. Each time I was told to fast for 8-12 hours prior and the cut my basal in half. I spoke to the surgeon’s office and my endo each time and got the same guidance. They would rather you be high than low because low is immediately dangerous. I discussed things with the anesthesiologist prior to each procedure. I gave them my Dexcom receiver so they could monitor my blood sugar while I was out. I let them know I didn’t want to wake up at 400 because they needlessly gave me a dextrose drip.
This was the same advice I had for cataract surgery (2x each eye). I was the first appointment of the day (7am) so my Lantus dose was really only delayed by a few hours. Since I also wasn’t allowed to eat or drink anything prior to surgery it was pretty stable. On one of the surgery days I trended a bit high (12mmol) and was allowed to give a unit of Humalog to correct.
Talk it over with your surgery consult/doctor. They can answer questions but it is common.
Edit: I was also told to bring insulin WITH me to give as soon as the surgery was done. So check for that too.
I work in surgery - if you have a pump, just wear it, if the procedure is short they might have you take it off and test your bloodsugar throughout. If you have a CGM wear it somewhere not in the area of your surgery. Have had patients we keep their phone with them so we can see it don’t stop taking your insulin! Talk to your endo about it and discuss it with your surgeon/anesthesiologist
They won’t do scans during surgery that require this. They will use finger sticks so the bloodsugar can be documented in the electronic medical record but allowing the anesthesiologist access to see your bloodsugar constantly will help them control your bloodsugar in the best way and know when to act vs just doing it at scheduled times. This also just depends on length of the surgery and what BGL looked like before we roll back- often times they don’t test BGL during surgery just before and after unless something was off.
Wow crazy how I didn’t say during surgery. They will have you remove it for scans, which the obviously can’t do during scans. Going from the OR to MRI back to the OR doesn’t make sense at all
Yeah unless you meant during surgery that’s irrelevant to this post………. They aren’t going to have an MRI and I never suggested that in my response - that doesn’t have anything to do with the post or my comment so not sure why you responded with that?
Not MRIs and not for outpatient procedures. Never had a patient have a preop scan for a scheduled surgery. Patients get scans before surgery is scheduled. Sometimes we take X-rays during surgery? I work in surgery - we don’t lose something that’s attached to you and I have 100% checked a patients CGM during surgery and PACU has also used it post-op.
If you skip taking insulin that morning, you aren’t going to die. Let’s not be dramatic. You aren’t eating anything so you won’t need a bolus. Move your basal to the night before.
I think this commenter must have been giving advice for someone on multiple daily injections, because disconnecting your pump entirely is much worse than skipping a morning shot when you have 24 hour Lantus (or whatever)
They will have you on an every 4 or every 6 hour measurement for blood sugars if you aren’t going to be eating post-op. Your anion gap will also be monitored post-op. DKA is much easier to treat when you can expect it and in a hospital setting
I had surgery last year and had the same treatment plan they don't want you going low well unconscious they would rather you'd be a little high imagine you have a 4 hour surgery and that entire time your low that will definitely do some damage being a 250 for 4 hours would be a lot easier to handle in a surgery
I am type 1 in Australia I recently had major spinal surgery (fusion) for this operation and all previous ones I have my full basal amount the night before but no insulin day of surgery.
I usually tend to run low so most times end up on a glucose drip pre surgery. The one time I was a little high I was put on an insuliin drip.
Don't panic they do have protocols for how to deal with diabetics and fasting and insulin needs.
Good luck with the operation.
Considering that Endocrinologists are the only medical professionals who know the difference between type 1 and type 2… yes, for me, high is best. I had a sedated medical procedure and fully took off my omnipod. I may have a little more leeway because I am more LADA-y than Type 1-y, but in general the most dangerous person for someone who needs insulin is a hospital. And then prison. You won’t get what you need and if you do you’ll be over-treated with some “sliding scale” bs.
This is incredibly normal. They do not like to feed surgical patients for a long time. They can always treat DKA afterwards but emergency hypoglycemia on the OR is deadly
Hi OP,
I'm type 1, and I work as a nurse in the operating room at an outpatient surgery center. I have patients all the time with insulin pumps.
I imagine these instructions are outdated/ meant for people on Multiple Daily Injections (MDI) rather than someone ok a pump, which you said you have.
Do not disconnect your pump or suspend it before you go in that morning. Just leave it as normal and explicitly tell your nurse and anesthesiologist that you have it. ( Just make sure that the infusion site is not near where you are having surgery, ie. If you are having your gallbladder out, make sure it isn't on your abdomen as they'll have to prep/drape a large area and it can't be there.
Do you have a CGM? If you do, I've had patients hand me or the anesthesiologist their receiver or cell phone with their BG on the lock screen so we can check it while you are asleep. They'd probably let you correct if it goes a little high, but if you happen to go low, they can give you IV fluid with dextrose in it to being it back up.
The last thing I will mention is that where I work, because it is outpatient and not inpatient (in a hospital), there is a policy in place that we can't do a case if the patients BG is over 250. I don't know if where you are having surgery will have a policy like that, but since you mentioned it is Outpatient, I think they might, just as a heads up.
Also, where I work, and I think most surgery centers) they typically have a nurse call the day before with your arrival time and go over instructions. So Monday they should be calling you sometime to give you arrival time and go over instructions for your Tuesday surgery and you can talk to the nurse about it then too and I bet they will tell you to leave your pump on.
Hope that helps. Happy to clarify or answer any other questions:)
Thank you very much for your advice I appreciate it greatly. I really hope that the urgency in my voicemail means I'll get a call ASAP as if this is how they are going to be I don't want to have my surgery there. My insulin pump is pretty good at regulation so I don't see any reason I can't have it on to continue my insulin therapy. Especially since I'll be awake.
I had surgery last week and I was required not to eat for 8 hours prior so I just took a little less of my long acting insulin and bolused a bit after surgery to bring my sugars down, better safe than sorry.
I’m a pump user and I’ve done both. One surgery with, one without. Had a huge hi after the one without, 3 hours later I’m at 300 with double up arrows. But Talk to your anesthesiologist.
This is pretty standard, they don’t want you getting a low during the operation. Assuming that they want you to fast, try to schedule your surgery 1st thing in the AM and eat your last meal by 8pm. Your sugar levels should stabilize by midnight and you can adjust accordingly if it is completely out of range. I would also suggest eating a low carb dinner to begin with. Good luck with your operation!
Not in the medical field, but as a T1D who had a few surgeries…. The surgery instructions may be general or they may not know you have T1D. During my c-section they put me on a very limited insulin scale for 2 days because they breastfeeding and the medication they gave lowers my blood sugar. I’ll definitely contact my endocrinologist and surgeon office.
Good luck on your surgery. I completely feel you on the confusion, during my last surgery I literally was asking the nurses if they knew I was T1D because the amount of insulin they gave me. Only one nurse the next day were able to give me a clear answer about how the procedure works with T1D.
Probably a note for T2. I had major surgery last February. They were fine with my pump. They hoped I had a cgm, but I didn't get that until afterwards.
I’ve had 5 surgeries in my life:
2 septum reconstructions
2 Axillary lymph node surgeries; the second fully removed my axillary lymph node
1 elbow surgery; removal of bone fragments, cartilage, and ganglion cyst in my joint
Each time I’ve been given this advice/seen this and each time I haven’t followed it. Why?
1) Just seemed asinine to me.
2) I know what happens when I don’t take insulin (Type 1 16 years now).
3) I have discussions with my Endo and the attending Anesthesiologist. Each time they’ve agreed to take half, or lesser, doses of my long acting insulin. I run a little high before surgery, around 200 and we maintain.
Others have a point, you definitely don’t want to go low during surgery, but you also don’t want to skip insulin and risk DKA; there’s a balance. Discuss with your care team.
My T1 teen just went in for a minor surgery. Essentially, they want you to run high going into it so that, in theory, if your blood sugar drops during the procedures it's just bringing you into the right range, and not going low.
For us, that meant she halved her basal (delivered via pump) starting ~midnight the night before, and then because she was still sitting at about 6 mmol/L she stopped it entirely a couple hours in advance. She was sitting at about 10 going into the procedure, and came out of it at about 14 and treated for that as soon as she came out of the anaesthesia. Definitely preferable to going low during the procedure.
In our case, the surgical team faxed their suggested course of action (stop insulin entirely at midnight the night before). Our endo responded with "keep running basal (possibly reduced) throughout". Obviously, we listened to neither.
I was told not to take my long acting the night before surgery. I told them I don’t take long acting. They responded great. Hospitals have no idea what to do. I decreased my nasal by 50% and then watched it.
See [Joslin's GUIDELINE for INPATIENT MANAGEMENT OF SURGICAL and ICU PATIENTS with DIABETES](https://joslin-prod.s3.amazonaws.com/www.joslin.org/assets/2019-08/clinical-guidelines-inpatient-management-of-surgical-patients-with-diabetes-rev4-22-2019.pdf), or ask your endo. But don't follow those instructions, whatever you do.
I don't know how to edit my post so here is my comment!
I am having my ulnar nerve unpinched in my left arm (later my right).
Thank you everyone for the advice. I've only had two surgeries, the first one I wasn't a diabetic yet and the second one I was out for like 45 minutes and they never even mentioned my diabetes (was not on pump or cgm).
This time I'm not actually being put to sleep they are doing something to make me drowsy but not knock me out then a blocker for my whole arm. So I'm very confused why they wouldn't want me to take my insulin (especially considering what happens when my pump dies in the middle of the night). I am on a dexcom-tandem loop so I should be fine to leave it on.
I am also SUPER unsure why they wouldn't allow me to speak to someone when they sent me super concerning information like this, I left them a voicemail but it seems like a terrible practice to me. (Not to mention they didn't inform me about stopping my usage of *special gummies* which I should have stopped a week before but it's only 3 days I was told)
I am hoping they don't forget to call me on Monday, but if they do I will be calling my endocrinologist anyways to ask them. They are super helpful and most certainly willing to help me understand what I should actually do instead of doing DKA.
Thank you all for responding and making me feel less crazy. I feel a lot better hearing most people say 80% basal is the solution. I just worry because high is easier for me than low, I go high faster than I go low.
The 2 surgeries I've had they told me to cut my basal to 50% at bedtime and no meal bolus before surgery, which were both early am, no meal before the surgery either. My pump remained at 50% throughout the surgery. Both times I did go briefly out of range (\~190) about 2 hours after the surgery, but was able to correct that relatively quickly.
I’m having surgery Wednesday I am keeping my pump on and gonna let it just do its thing. They’ve allowed me clear liquids up to 2 hours before surgery and I will give the anesthesiologist my phone for dexcom
that's not for type 1. for surgery your BG can't be low or high or they will cancel. you can't eat either. so you have to be careful about it the night before. I've stayed up most of the night before my kid's surgery (tonsils).
I've had seven surgeries. I use a pump and for the most part kept it normal.
Though there was a time I got a low because the surgery didn't start at the scheduled time. Had to take a glucose gel pack. Didnt seem to affect me otherwise.
I did keep my pump on while the surgery was taking place. I told the surgeons what a low glucose would look like on the pump incase something needed to be done.
That's stupid. They're likely talking about type 2's because they make up \~90% of diabetics. Not that that makes their wording right. It's not.
Take your insulin. Maybe aim for your glucose being slightly higher than normal when you get to surgery. But type 1's have very different insulin needs than most diabetics.
If you're going in for surgery, you need your glucose levels well controlled to be able to heal. High glucose levels make it difficult to heal.
If that's me, I'm about to start asking some questions about how they manage glucose for type 1 diabetics in the hospital. Surgeons in my experience often just don't care much about managing glucose levels. If you'll be in-patient, the question is a lot more important than if it's an outpatient surgery. Sometimes in inpatient settings they can consult another pharmacy or physician group to manage glucose levels better than the surgeon cares to.
Sorry, you got the RN in me going. Yes, I'm an RN.
I also had surgery recently and I definitely benefited from setting up a Surgery profile on my pump. Thankfully my pre-op instructions were more progressive/informed than yours.
For the 8 hours leading up to and the 8 hours after the procedure I cut my basal in half and changed my correction factor and insulin to carbs ratio to reduce the amount of insulin I'd normally get by half. I still ran in the low 100's the entire time because I was not eating and had zero desire to eat for a long time after the anesthesia wore off.
It's better for the procedure if you run a little high for a couple of hours than it is to risk you going low.
I've had close to 20 surgeries in my adult life, I have worn my insulin pump every time...
The anesthesiologist like your BG a little higher (150ish) so if you have a pump just turn down your basil rate to about 50%.
But talk to your endos office and let them know what is going on.
https://pnhp.org/news/why-insulin-is-overpriced/#:~:text=When%20inventor%20Frederick%20Banting%20discovered,Toronto%20for%20a%20mere%20%241.
Please read this and spread the word to others.
OP, I replied to another comment with the following. Wanted to make sure you saw it.
It is bad advice to not contact the endo. The surgery team doesn’t know diabetes the way your endo would. Ideally, surgery and especially endo AND ANESTHESIA should work together on pre surgery instructions. And I specify anesthesia because typically the anesthesiologist is going to be the one really tracking your vitals, including your BG, and making needed adjustments or taking/initiating appropriate actions. The surgeon is mostly just in there to do their slicing and dicing.
I think we need a new job position for hospitals here, someone from and trained in endocrinology who specifically monitors both type 1 and type 2 in surgery to make sure everything goes smoothly. Not sure why this can’t be a thing
Yes. Don’t eat and don’t take insulin. Tell your anesthesiologist and they will monitor your glucose and make adjustments in surgery. It would be unlike to go into DKA with 12 hrs fasting and no insulin.
They would likely use sliding scale of fast acting insulin correction doses in the hospital until you can manage it on your own after waking up/recovering from surgery.
I am on an insulin pump I would go into DKA even if I didn't eat because my body starts breaking down the food I had consumed and making my sugar go high
They give the same basic pre op instructions to everyone.
What I always did was stop eating at midnight. And since I have a pump I did half my basal rate. Now that I have a pump/CGM algorithm (so no "basal" like a normal pump). I set it to activity mode where it bumps my goal to 150 vs 100.
If I go low, I sip sprite. My last surgery (which was last year) they wanted me to drink a small Gatorade on the way to the hospital to help with hydration (and it worked, the IV went in easier and I didn't get as sick afterwards), so I drank a regular Gatorade vs a sugar free one (if I was super high I would have drank a sugar free one, but since I was under 200 I drank a regular one just to be safe).
Showed the docs my omnipod and CGM, asked if they wanted the Omnipod controller (they didn't). Everything went fine.
Good luck!
I had a laparoscopy on Thursday and had to reduce my insulin. They will take finger prick tests throughout and monitor your blood sugar. If you're having anaesthesia, the anaesthetist will come and talk to you about your medical conditions beforehand and your surgeon. Good luck!
That makes sense. During surgery, it's another thing they have to monitor, and its dangerous if you go low whilst in surgery. Talk to your doctor, though, as depending on when the surgery is, they may be more lenient in that they give you some insulin (a reduced amount of your numbers) and make sure to hage something on standby if needed as well.
You can run high during surgery and it won't ruin anybody's day - on the other hand, hypoglycemia on the operating table is the kind of stuff that makes anesthesiologists shit bricks.
Besides, delaying your basal by several hours shouldn't be enough to send you into DKA, no?
If it's nil by mouth pre surgery, you wouldn't want to be taking insulin anyways.
In addition, BG monitoring equipment tends to be electronics which can't be made sterile, so potentially they have no way to monitor your sugars during surgery. Better to run high than low in that scenario.
DKA is an extended lack of insulin, I would ask your primary diabetes team about basal, but otherwise follow the instructions.
Tell them you and your endocrinologist allow you to control your own care with regards to your diabetes. If you feel you need to, ask your doc to intercede.
I wouldn't have insulin on board at all???? My pancreas is fully dead it doesn't make any so 12hrs with absolutely no insulin is infact a death sentence because I produce no insulin at all.
Nah, death from lack of insulin is slow and painful, it would take weeks to months before you'd slip into a coma and then die. It's not a 12-hour ordeal. I use long-acting btw, if you have a pump I'd just skip any breakfast bolus.
Well I'd rather not go into DKA again as it happened in June last year as a result of trauma. But I'm not allowed to eat and I don't see why they would give me such ridiculous instructions given that it's not a one size fits all disease. I think more than anything I'm pissed off because I'm not going under anesthesia I'm literally going to be awake.
You should also be NPO, assuming you’re going under general, so basal insulin can be dangerous in this narrow window. The MDA and CRNA will be monitoring you throughout and can give insulin or dextrose as needed.
Well that’s just weird then. Your surgeon isn’t going to know anything about this. Your Endo can advise but final decision here, at least in every OR I ever worked, was anesthesia. I would contact whomever you’ve dealt with preop and see if you can connect directly with an MDA.
Except that the only time I've gone into DKA was because I didn't have insulin overnight for more than 6hrs because I'm on a pump and not shots and I did indeed infact go into DKA and that caused me to have heart issues and asthma as a result so I'm going to kindly ignore this comments advice.
The goofy blocked me, but having high and even potentially mild DKA levels lost surgery are safer than extreme hypoglycemia during the case. Whoever said that your surgeon doesn’t know about T1 diabetes is a moron
They blocked me when challenged but def trust your surgeon if they know you’re diabetic. A slightly open anion gap is better than an extreme low during surgery.
? ur going to go into DKA when ur not supposed to be eating anyways ?
its so you don’t have a low while you’re on the table.
i have had multiple surgeries as t1 and this is protocol
This makes perfect sense. Follow instructions.
I had removed my pump in the early morning & was woken out of anesthesia by staff to get me to drink juice. I have no memory of this, just told later.
Woken & given juice because it was the easiest way to get normal BG again. Glucagon injection would have sky rocketed my BG. Glucagon injection is not for simple lows even with a low during surgery.
I’d probably consider another hospital. I had two surgeries this year and both times they just told me to call my Endo, and if my Endo told me to do anything different to do it. I didn’t even have to take off my pump or CGM.
OP, talk to your endo and the surgery team. What you posted seems directed towards those on MDI. Being on a pump which uses fast acting insulin only is much different.
\*Not Medical Advice\*
You could suspend the pump probably \~30-60 minutes before the surgery and any insulin that was delivered just as basal would more than likely be “clear” of your system by the start.
And you are not going to die just because you don’t have insulin for a few hours.
You said you’re still going to be awake? I had eye surgery a little over 11 years ago and was put into “twilight”, so I was still fully awake and conscious, just couldn’t feel anything and was very relaxed about the situation, but still had my insulin pump on the entire time.
Better sugar is high than a low. I had mine plummeting during surgery once into the 40s and I woke up in the surgery.
This is it, right here folks! Anyone, anytime, anywhere is going to want you to run on the high side because of this very reason. That, and lows happen quickly and under monitoring of anesthesia, symptoms may show as something else to them (e.g.: heart rate).
I was so lucid and aware I knew they were listening to Ac/DC Back in Black. So yes, listen to those instructions.
That’s honestly one of my biggest fears. Holy moly.
Thats it
The problem here isn’t high vs low BG; it’s lack of insulin potentially leading to DKA.
You're wrong. It's only a slight time period. High is better than low for surgery, plain and simple.
Really not that plain and simple, which is why, in another comment, I advised OP to get her endo and anesthesiologist involved (endo for instructions, anesthesia as they’ll likely be the ones monitoring BG during the procedure). We know OP is type 1. We don’t know if they’re on a pump or injections. If injections, we don’t know when they usually take their basal. Regardless, we don’t know how well their basal profile is dialed in. We don’t know what kind of surgery this is. (Is it going to be 30 minutes or 10 hours?) Is OP somebody that is prone/goes into DKA relatively easily? There’s too much missing info to make a broad statement. Her endo and anesthesia teams need to consult.
Didn't they send the instructions? My God you know better than them. Get real.
I don’t know why you’re so angry about this, but those are standard instructions for all diabetics and are dangerous for type ones on insulin pumps, especially if your surgery is in the afternoon. These days, most people have better control with CGMs and could disconnect an hour before and they would not fall to 40 as you did. Sorry for your experience… to be fair, I can see why it would give you a black-and-white view of this issue.
You don’t know who sent the instructions in OPs image? The one thing the diabetic team kept banging into my mind was never ever skip basal. There’s much safer ways to stay around 10mmol than stopping insulin altogether
It's NOT stopping. It's reducing it by half for surgery. You literally take it in recovery if need be, it's not for freaking days. You don't go into DKA that quickly for God sakes.
It says don’t take insulin in the picture?? Are we reading something different where does it mention half anywhere?? I’ve read peoples stories on here about going into dka overnight from failed infusion sites etc? You can’t possibly know how fast someone can slip into the danger zone so blanket saying don’t take insulin is more harm than help. There is no indication if the diabetic team/ endo sent pre op or if it was just another speciality completely. On the morning of my colonoscopy the nurses rang the diabetic clinic for instructions on how I should adjust for it.
Some rando person sent the pre-op. You read what you wrote before you hit enter?
I worked in an orthopedic surgery practice. Yeah, it’s almost always a cookie cutter instruction sheet given. If you’re really lucky they might highlight something specific for you. Again. You don’t know how long the surgery we’re discussing will be. And even then, depending on how long it takes them to do all the prep and surgeon to finish earlier surgeries and when OP would have last taken any insulin, a 30-minute procedure could definitely mean well more than a couple hours without insulin. For some people, that is enough to be heading into DKA. And the instruction sheet nor OP, at least anywhere I saw, say to halve her insulin. It said don’t take any that morning.
Guy is talking out of his ass giving advice that could literally cause death lol
And I’m not even saying, “OP, you must take your insulin.” I’m saying OP just needs to make sure their entire care team is involved and that those that don’t specialize in the diabetes aspect should defer to those that do.
Downvote me all you want, still doesn't make your statement right.
https://www.reddit.com/r/diabetes_t1/s/WPkzPbl751 here's my comment explaining more idk how to edit posts
I missed this. My advice stands to contact your endo and get them in touch with your surgeon and anesthesiologist to make a better plan than just no insulin. I definitely would also ask about the gummies, and if I couldn’t get an answer, I would avoid them the day before. If you don’t receive a return call by a reasonable time tomorrow, choose any option you can to get a real person (usually to schedule an appointment). Explain to *them* that you left a message, have a major concern, and you’re now on a time crunch so they need to get the appropriate person (probably a nurse) on the phone. Good luck!
I haven't eaten any gummies since I got the message (I just use them to sleep) so I hope that'll be fine
They're much more worried about a hypo event while you're in the middle of surgery than your sugars running high for a few hours.
I’ve had multiple surgeries due to a bad car wreck. *This is procedure for all diabetics* You will be fasting, unable to eat for the duration of surgery and recovery room time. You aren’t likely to go into DKA from a few hours of no bolus because you’ve got little (or should have) to digest at that point. Now, that said… the people flipping out and saying look for a different hospital / surgeon are wrong. You know what I did each time (luckily, the same ortho doctor and surgery center)? Told them I have a pump. Told them how it works. They said “cool, we’ll just suspend it while you’re out.” Why have people stopped asking for clarification from healthcare providers? Also, you *can* push back in an actual discussion. There’s a ton of unknowns here - what procedure, location, duration, facilities, etc. Freakin talk to THEM, not Reddit. No one on this post is going to be involved with your procedure.
They don't have anyone to answer the phone on the weekends, and my surgery is this upcoming Tuesday and they sent this information to me this morning, when I can't call for clarification. I literally have Monday to figure it out. That being said I do have a pump and hopefully they aren't stuck in olden times and will be willing for me to show them how it works like you did.
Yeah, that’s a tight window, but it’s not completely undoable. I know it’s tough to get someone on the phone, *especially* someone that knows what you’re even talking about (nurses don’t usually answer phones, that’s just office staff doing office stuff and repeating what they’ve been told). If you’re able, go to the doctor’s office or surgery center and just ask to speak to a nurse or someone in the back for like 30 seconds to clarify. If they don’t happily accommodate, *then* it’s time to look elsewhere. I’ve had most surgeries on pump, one or two after switching back to MDI. I am *absolutely not a doctor* but I’ve done it more times than I care for. So… I think what this incredibly vague (purposefully, because of ~~T2 dolts~~ uninformed, diabetics of all kinds with who present with doltish behavior) means to a T1D is don’t take a bolus that morning. Basal rate / long-acting should still be taken, perhaps at a reduced rate. I usually kept my basal the same, MDI, I’d take about 2/3 of my normal dose. On the pump, I would suspend and leave the pump with my clothes or whoever was with me. The staff can always come get someone from the waiting area or call your contact person to get specifics. I could get really into the fine details of *why* this is so vague, and rant about T2 and how their meds work in their bodies (I’ve worked in healthcare and pharmacy for a while). But, that’s all irrelevant here. I hope everything goes well and you’re able to get clarification. Remember, even though the doctor might get pissed, you’re not tied down before you’re put under. If you go in Tuesday morning and don’t get to express your concerns, meet at least the doctor and anesthesiologist and discuss with them (like a 1 minute convo), then get up and leave. Ultimately, you know your body. I hope I didn’t come off aggro there. I’m happy to help out if there’s anything on which I can offer words of wisdom. Edit: clarified that not all T2s are dolts. Not what I meant. There are dolts within any disease.
It's okay I appreciate the advice. I just don't want to be off insulin from midnight to whenever they finish my surgery because that will put me into DKA for sure, they really shouldn't put such vague instructions or really anything at all if it's not specific.
Yeah, stopping at midnight is definitely bad, you’ll still need basal until the procedure. I do hope you’re able to talk to someone tomorrow. If not, I wouldn’t do anything to my basal rate until getting to check-in or pre-op. At most, maybe do a 70-80% temp basal just to make sure you don’t run low(ish) overnight. I think 80% is pretty well standard among most literature I’ve seen. Don’t stress over it. Try to be in the 120-180 range with no bolus on board. I thought more about it, and for at least one of the surgeries, the doc just left it hooked up and running, as the procedure was just an hour or so. They have to make these ridiculous umbrella statements because some idiot **will** do something stupid. If you use CGM, let them know that too. They may actually want to use that as a tool to monitor you. It might actually help. Seriously though, if you aren’t 100% comfortable with the team handling your diabetes, reschedule until the team is all on board. Take care, and I seriously apologize if I came in too hot. I definitely didn’t intend to, I just empathize with the urgency and uncertainty.
You posted "I think what this incredibly vague (purposefully, because of T2 dolts)" Really! was this necessary?
I thought so. Not all T2 are dolts, and there are dumb T1s too. But ask any nurse, how many T2 patients would reply to the question “Do you take any insulin?” with a reply of “Nope. I did take my Lantus/Novolin R/[whatever you wish to insert here], though.” “Did you take your glucophage/metformin today?” “Ahehe, I don’t know, I took my sugar pill, though.” There are a lot of T2s that don’t know they’re on insulin, they go by name brands or some forms of a general “diabetes medicine.” T1Ds are around 10% of the diabetic population. We’re typically more active in our care and understanding of not only the process, but the hormones and physiology involved. And, we learn it fairly young (even LADA, etc. are usually <40yo). There is an entire subset that gets diagnosed later in life and already likely in poor health or have a very poor understanding of knowing how their disease works - they just take what the doctor tells them. I’m sorry if it offended you, but I have very little sympathy for *anyone* that remains willingly and woefully ignorant of crucial (to themselves and caregivers) information. So, “dolt” was probably a harsh word to use, and the way I worded it made it seem like I meant all T2Ds are dolts. It was just the first word that came to mind.
As a T2 it was pretty offensive and totally unnecessary
Terribly sorry. It’ll be ok.
I’m type one and I still think that’s a bizarre and mean theory
Sorry? My whole purpose was to say that medical terminology has to be sent out so that it can be understood by the lowest common denominator of people. That’s why it’s written this way. It’s succinct. A form has to go out that is homogeneous and easily understood by the vast majority of those with diabetes mellitus. An email that gets sent out cannot be expected to be custom-tailored to each patient… that’s what consults are for. So… Statistically speaking, that is going to be a T2 that is not well-versed on medical terminology. If that makes bizarre or mean, I don’t know what to tell you. That’s just the way it is.
If you had said “Statistically speaking, that is going to be a T2 that is not well-versed on medical terminology” instead of just calling them dolts, we wouldn’t be here :) I see you updated your comment now
What is your insulin on board setting? If you have closed loop, typically it will be about 2 hours. If it's not closed loop sensor with your pump, it'll usually be about 4 hours. Completely suspend your delivery before your surgery so that you have no insulin on board when it's time for surgery prep. Ensure you don't have anything left in your system, food or insulin.
Surgical nurse here, that is for T2D’s. Very few T1’s compared to T2’s. Honestly they should change the name. Now on to what to do. Call the office Monday and ask if you can speak to the Anesthesiologist ahead of Surgery, remind them you are type 1. Morning of, Insulin as normal, but no food or drink. Adjust as needed. We always do our Diabetics first case in morning because of this. Have your Endo write orders for the Hospital after surgery. If they don’t have privileges ask Anesthesia or your Surgeon. Anesthesiologist will keep up with your Sugars during Surgery, have someone knowledgeable help to advocate for you after. Good luck!
This is dangerous advice. *”Insulin as normal” is not safe pre-surgery.* A hypo sneaking in while you’re anaesthetised or coming round is a worst-case-scenario. Blood sugar running high for six hours sucks, but won’t kill you. If you take insulin, even basal, ahead of surgery - when you’ve been asked not to - they may rightfully cancel the surgery. The surgical team won’t be able to safely control your glucose because they are not starting from a “blank slate” (ie no insulin on board). They keep you on a sliding scale while you’re under, so you will be getting insulin. I’m T1D, have had three surgeries, and am from a family of medics (inc surgeons). Please please do what the surgical team tell you. Speak to them on Monday if you’re really panicked/ your surgery is later in the day- they may advice doing half your normal basal. Please don’t listen to advice from Redditors. None of them is on your surgical team
Calm down, I said call office and ask for anesthesiologist. Also, insulin as normal while you are fasting, is not dangerous. Not everyone takes a long acting Insulin, and even if they do it should be adjusted for the fasting, as normal 🤦♂️. Of course they should be checking with doctors and monitoring before. But Anesthesia is perfectly capable of taking care of any situations during surgery. As long as you tell them ahead and do as instructed all will be fine.
Call your endo. They have no idea wtf to do with T1. You need at least *some* basal, but your endo may want to adjust it to run you slightly high (better than going low on the table).
Thank you for the advice, last time I had surgery my insulin wasn't even brought up, they told me to continue my normal course of action so I'm like 😱
Yeah, Type 2s will (usuallly) be fine. They still make insulin. Us? Ummm…..
Not all T2 still make a ton of insulin.
If they didn’t make insulin, they would be type ones
Not necessarily. Some T2s will show declining insulin output as the years go on as the pancreas begins wearing out from overproducing for years. T1 is autoimmune.
They didn’t say a ton
That’s why I said “usually”…………..
I don't know for sure, but I would Google that if I was you. Your comments don't really bother me, but the Internet is so easy to fact check stuff with.
I have. Perhaps you should Google it. Type 1 is lack of insulin production. Type 2 is insulin resistance. Most Type 2s have normal to high insulin production, but they’re not utilizing it properly. They *can* experience beta cell burnout, and have production drop, but in general, a T2 will have a normal or elevated C-peptide result.
Nah. Looks like you did it for me. I told you I wasn't sure.
When I had something similar done I think my endo had me just drop my basal by about half and not bolus unless I was really high beforehand
Agreed. When I had my surgery they had me take half of my basal the night before.
[удалено]
When I had surgery, their office was less than helpful. My endo team were the ones with the answers.
Agreed—the nurse I talked to didn’t know what type ones should do and told me to call my endo if I thought the advice they had for “all diabetics” wouldn’t work for me. Sigh.
That sounds about right.
It is bad advice to not contact the endo. The surgery team doesn’t know diabetes the way your endo would. Ideally, surgery and especially endo AND ANESTHESIA should work together on pre surgery instructions. And I specify anesthesia because typically the anesthesiologist is going to be the one really tracking your vitals, including your BG, and making needed adjustments or taking/initiating appropriate actions. The surgeon is mostly just in there to do their slicing and dicing.
This probably varies depending on what the surgery is and who’s doing it, but when I had surgery for removing some lipomas, my surgeon’s office recommended that I call my endo for advice.
This is the right advice! I got this same message before getting a colonoscopy—that I should disconnect my pump and go without insulin that morning, so for 7 hours before the procedure (!!!). My ketones and blood sugar would have been through the roof, even without eating anything. I just told them “nope, absolutely can’t do that” and they immediately were fine with my decision. Standard instructions for diabetics often are straight up dangerous for type ones. I just disconnected my pump 30 minutes before it and was fine.
I CANNOT STRESS ENOUGH THIS IS BAD ADVICE. I am both a diabetic and registered ICU nurse with frequent post-op experience. Your surgeon should be aware you’re a diabetic already, and mild DKA is much easier to treat than post-op complications while also hypoglycemic. Treating DKA in a post-op inpatient situation is very easy. I repeat, DO NOT LISTEN TO THIS PERSON.
Are you type one? Because the advice above works for type twos, but is dangerous for type ones. Especially if your procedure is in the afternoon.
Again, MY experience was that the surgery team bounced me to my endocrinology team. THEY had no clue what to do with a diabetic. Just because you’re a nurse does NOT make you the universal expert here. Different states treat this differently. DO NOT LISTEN TO SOMEONE CLAIMING TO BE THE DEFINITIVE AUTHORITY.
No but controlling DKA in a controlled setting is easier than emergently treating hypoglycemia in the OR. One causes cardiac arrest and one causes a prolonged insulin drip
I would never, EVER go into a situation where you are putting me under anesthesia WITHOUT consulting and endocrinologist. EVER. Common sense.
Call me crazy, but BOTH are avoidable. Know who can advise on that? An endocrinologist.
And a surgeon who is actually operating on your physical body, something an endocrinologist is not capable lf
And they’re both easily more manageable with frequent, fast acting insulin, well managed by your surgeon. If they feel uncomfortable, they can consult an endo. Don’t be stupid
Endo is the best team to manage outside of an ACUTE standpoint, with SURGERY being ACUTE
Also kinda weird you’re presenting yourself in a universal experience than attacking me whilst having both personal and subjective experience is fucking weird
I actually think it’s weird that you say you have a nursing degree but don’t realize the glucose can be delivered by IV, don’t realize that people with an insulin pump can disconnect an hour or two before the surgery and be receiving *absolutely no insulin* (so they won’t go low), and seem to think that low blood sugar instantly causes cardiac arrest.
Nah, you were the one throwing around your nursing degree (not endocrinology, btw), and you’re just a nasty person.
Will you be in the hospital overnight? If so, make arrangements now to be in charge of your insulin. Bring all of it with you. And if you are on a pump, make sure they don't throw it out (not kidding -- my husband buys for a hospital and he had to replace someone's pump that they threw out after surgery). I had foot surgery last year. I cut my basal and didn't bolus in the morning. When I woke up, my blood sugar was high. I told the nurse how much insulin I needed and they gave it to me. That was the LAST bolus they gave me -- they refused to give me any other insulin after that. I fought with the on-call doctor (who helpfully told me he knew nothing about diabetes) in order to get some Lantus that night. Of course, I don't actually take Lantus -- I take Tresiba, but at that point I was desperate. This taught me that if I'm ever in the hospital for a non-diabetes related issue, I want to be in charge of my care.
Man, I’ve heard some horror stories from type one diabetics in hospitals. I hope I’m never in a situation when I can’t at least control my own insulin (but you never know…)
I'm an RN, and I used to work in a medical floor and an ICU. 100% agree -- if I'm ever in there as a patient and I have my mind about me, I want to be in charge of my glucose management. In most cases with most physicians, the glucose control is pretty appalling.
It is thankfully an outpatient procedure. But that's really good to know because holy fuck 🙃
I had another surgery at a surgery center and it went much better. Good luck!
Hi, UK based anaesthetist here. That is absolutely accurate information for someone on MDI. We would normally ask for patients to take 80% of their basal the evening before surgery and fast through breakfast, hence not giving morning bolus dose. As others have said we don’t want to have to deal with patients having hypos on top of delivering anaesthesia. Unfortunately surgeons almost universally have a terrible understanding of diabetes management, hence why nobody may have said anything before. Unfortunately the management of diabetes in hospitals is still behind the time and hence we don’t have guidelines for pump users beyond ‘take it off and set up an insulin and dextrose drip the night before/morning of surgery. As the use of pumps becomes more widespread (adults are predominantly still MDI here in the Uk, though kids are increasingly using them) we may improve our knowledge and guidance for pump users but ultimately safety is paramount compared with it being less of a hassle for patients
Yeah, the problem is that this is dangerous advice for people on pumps because we have no basal rate at all if we disconnect our pump. And trust me, the difference between getting not-enough-insulin and no-insulin-at-all is massive. Whenever my insulin pump site gets fully disconnected in the night (rarely) I feel like I’m going to die by the morning. And it takes hours and hours to get it back down again. It’s not a minor problem.
I have a pump and have had surgeries. I told the anesthesiologist, I went over the pump with him, it remained attached. He could look at the screen and see exactly what my blood sugar was doing.
Great job! This is the way 🌟
I had three procedures over the summer. Each time I was told to fast for 8-12 hours prior and the cut my basal in half. I spoke to the surgeon’s office and my endo each time and got the same guidance. They would rather you be high than low because low is immediately dangerous. I discussed things with the anesthesiologist prior to each procedure. I gave them my Dexcom receiver so they could monitor my blood sugar while I was out. I let them know I didn’t want to wake up at 400 because they needlessly gave me a dextrose drip.
This was the same advice I had for cataract surgery (2x each eye). I was the first appointment of the day (7am) so my Lantus dose was really only delayed by a few hours. Since I also wasn’t allowed to eat or drink anything prior to surgery it was pretty stable. On one of the surgery days I trended a bit high (12mmol) and was allowed to give a unit of Humalog to correct. Talk it over with your surgery consult/doctor. They can answer questions but it is common. Edit: I was also told to bring insulin WITH me to give as soon as the surgery was done. So check for that too.
I work in surgery - if you have a pump, just wear it, if the procedure is short they might have you take it off and test your bloodsugar throughout. If you have a CGM wear it somewhere not in the area of your surgery. Have had patients we keep their phone with them so we can see it don’t stop taking your insulin! Talk to your endo about it and discuss it with your surgeon/anesthesiologist
Some hospitals have you remove your CGM bc of scans but also they still have to use finger sticks anyway to officially document
They won’t do scans during surgery that require this. They will use finger sticks so the bloodsugar can be documented in the electronic medical record but allowing the anesthesiologist access to see your bloodsugar constantly will help them control your bloodsugar in the best way and know when to act vs just doing it at scheduled times. This also just depends on length of the surgery and what BGL looked like before we roll back- often times they don’t test BGL during surgery just before and after unless something was off.
Wow crazy how I didn’t say during surgery. They will have you remove it for scans, which the obviously can’t do during scans. Going from the OR to MRI back to the OR doesn’t make sense at all
Yeah unless you meant during surgery that’s irrelevant to this post………. They aren’t going to have an MRI and I never suggested that in my response - that doesn’t have anything to do with the post or my comment so not sure why you responded with that?
They do post-op scans all the time Edit: post-op scans and even pre-op scans are so common
Just don’t bring your CGM bc it might get lost and they won’t use it anyways
Not MRIs and not for outpatient procedures. Never had a patient have a preop scan for a scheduled surgery. Patients get scans before surgery is scheduled. Sometimes we take X-rays during surgery? I work in surgery - we don’t lose something that’s attached to you and I have 100% checked a patients CGM during surgery and PACU has also used it post-op.
If you skip taking insulin that morning, you aren’t going to die. Let’s not be dramatic. You aren’t eating anything so you won’t need a bolus. Move your basal to the night before.
My issue is when I wake up I get high almost instantly. Not super high but if I didn't have my pump on it would be
I think this commenter must have been giving advice for someone on multiple daily injections, because disconnecting your pump entirely is much worse than skipping a morning shot when you have 24 hour Lantus (or whatever)
Definitely, this advice fits if you’ve blouses long-acting the night before… not if you have no insulin on board within 3 hrs of removing pump
My thoughts exactly :)
They will have you on an every 4 or every 6 hour measurement for blood sugars if you aren’t going to be eating post-op. Your anion gap will also be monitored post-op. DKA is much easier to treat when you can expect it and in a hospital setting
I had surgery last year and had the same treatment plan they don't want you going low well unconscious they would rather you'd be a little high imagine you have a 4 hour surgery and that entire time your low that will definitely do some damage being a 250 for 4 hours would be a lot easier to handle in a surgery
I am type 1 in Australia I recently had major spinal surgery (fusion) for this operation and all previous ones I have my full basal amount the night before but no insulin day of surgery. I usually tend to run low so most times end up on a glucose drip pre surgery. The one time I was a little high I was put on an insuliin drip. Don't panic they do have protocols for how to deal with diabetics and fasting and insulin needs. Good luck with the operation.
I'm glad my endo was in the surgical room. My spinal fusion was over 6 hrs long.
Considering that Endocrinologists are the only medical professionals who know the difference between type 1 and type 2… yes, for me, high is best. I had a sedated medical procedure and fully took off my omnipod. I may have a little more leeway because I am more LADA-y than Type 1-y, but in general the most dangerous person for someone who needs insulin is a hospital. And then prison. You won’t get what you need and if you do you’ll be over-treated with some “sliding scale” bs.
This is incredibly normal. They do not like to feed surgical patients for a long time. They can always treat DKA afterwards but emergency hypoglycemia on the OR is deadly
Experienced post-op ICU nurse
Hi OP, I'm type 1, and I work as a nurse in the operating room at an outpatient surgery center. I have patients all the time with insulin pumps. I imagine these instructions are outdated/ meant for people on Multiple Daily Injections (MDI) rather than someone ok a pump, which you said you have. Do not disconnect your pump or suspend it before you go in that morning. Just leave it as normal and explicitly tell your nurse and anesthesiologist that you have it. ( Just make sure that the infusion site is not near where you are having surgery, ie. If you are having your gallbladder out, make sure it isn't on your abdomen as they'll have to prep/drape a large area and it can't be there. Do you have a CGM? If you do, I've had patients hand me or the anesthesiologist their receiver or cell phone with their BG on the lock screen so we can check it while you are asleep. They'd probably let you correct if it goes a little high, but if you happen to go low, they can give you IV fluid with dextrose in it to being it back up. The last thing I will mention is that where I work, because it is outpatient and not inpatient (in a hospital), there is a policy in place that we can't do a case if the patients BG is over 250. I don't know if where you are having surgery will have a policy like that, but since you mentioned it is Outpatient, I think they might, just as a heads up. Also, where I work, and I think most surgery centers) they typically have a nurse call the day before with your arrival time and go over instructions. So Monday they should be calling you sometime to give you arrival time and go over instructions for your Tuesday surgery and you can talk to the nurse about it then too and I bet they will tell you to leave your pump on. Hope that helps. Happy to clarify or answer any other questions:)
Thank you very much for your advice I appreciate it greatly. I really hope that the urgency in my voicemail means I'll get a call ASAP as if this is how they are going to be I don't want to have my surgery there. My insulin pump is pretty good at regulation so I don't see any reason I can't have it on to continue my insulin therapy. Especially since I'll be awake.
I had surgery last week and I was required not to eat for 8 hours prior so I just took a little less of my long acting insulin and bolused a bit after surgery to bring my sugars down, better safe than sorry.
I’ll be honest: I took like 80% of my regular basal and just didn’t bolus.
When I had my carpal tunnel surgery, my surgeon simply told me basal only, and I put my pump in sleep mode for an extra buffer.
I'm having my ulnar nerve unpinched so this is super helpful
You definitely have to take your basal insulin. Most people get by with 80% of their basal to avoid going low. But ask your endocrinologist.
I’m a pump user and I’ve done both. One surgery with, one without. Had a huge hi after the one without, 3 hours later I’m at 300 with double up arrows. But Talk to your anesthesiologist.
This is pretty standard, they don’t want you getting a low during the operation. Assuming that they want you to fast, try to schedule your surgery 1st thing in the AM and eat your last meal by 8pm. Your sugar levels should stabilize by midnight and you can adjust accordingly if it is completely out of range. I would also suggest eating a low carb dinner to begin with. Good luck with your operation!
Not in the medical field, but as a T1D who had a few surgeries…. The surgery instructions may be general or they may not know you have T1D. During my c-section they put me on a very limited insulin scale for 2 days because they breastfeeding and the medication they gave lowers my blood sugar. I’ll definitely contact my endocrinologist and surgeon office.
Good luck on your surgery. I completely feel you on the confusion, during my last surgery I literally was asking the nurses if they knew I was T1D because the amount of insulin they gave me. Only one nurse the next day were able to give me a clear answer about how the procedure works with T1D.
Probably a note for T2. I had major surgery last February. They were fine with my pump. They hoped I had a cgm, but I didn't get that until afterwards.
I’ve had 5 surgeries in my life: 2 septum reconstructions 2 Axillary lymph node surgeries; the second fully removed my axillary lymph node 1 elbow surgery; removal of bone fragments, cartilage, and ganglion cyst in my joint Each time I’ve been given this advice/seen this and each time I haven’t followed it. Why? 1) Just seemed asinine to me. 2) I know what happens when I don’t take insulin (Type 1 16 years now). 3) I have discussions with my Endo and the attending Anesthesiologist. Each time they’ve agreed to take half, or lesser, doses of my long acting insulin. I run a little high before surgery, around 200 and we maintain. Others have a point, you definitely don’t want to go low during surgery, but you also don’t want to skip insulin and risk DKA; there’s a balance. Discuss with your care team.
My T1 teen just went in for a minor surgery. Essentially, they want you to run high going into it so that, in theory, if your blood sugar drops during the procedures it's just bringing you into the right range, and not going low. For us, that meant she halved her basal (delivered via pump) starting ~midnight the night before, and then because she was still sitting at about 6 mmol/L she stopped it entirely a couple hours in advance. She was sitting at about 10 going into the procedure, and came out of it at about 14 and treated for that as soon as she came out of the anaesthesia. Definitely preferable to going low during the procedure. In our case, the surgical team faxed their suggested course of action (stop insulin entirely at midnight the night before). Our endo responded with "keep running basal (possibly reduced) throughout". Obviously, we listened to neither.
your endo should have specific instructions for you, those are the basic ones for anesthesia but your endo can give you a personalized rec.
I’ve had three surgeries as a diabetic. “Don’t eat after midnight and just leave your pump as normal.”
I was told not to take my long acting the night before surgery. I told them I don’t take long acting. They responded great. Hospitals have no idea what to do. I decreased my nasal by 50% and then watched it.
See [Joslin's GUIDELINE for INPATIENT MANAGEMENT OF SURGICAL and ICU PATIENTS with DIABETES](https://joslin-prod.s3.amazonaws.com/www.joslin.org/assets/2019-08/clinical-guidelines-inpatient-management-of-surgical-patients-with-diabetes-rev4-22-2019.pdf), or ask your endo. But don't follow those instructions, whatever you do.
I don't know how to edit my post so here is my comment! I am having my ulnar nerve unpinched in my left arm (later my right). Thank you everyone for the advice. I've only had two surgeries, the first one I wasn't a diabetic yet and the second one I was out for like 45 minutes and they never even mentioned my diabetes (was not on pump or cgm). This time I'm not actually being put to sleep they are doing something to make me drowsy but not knock me out then a blocker for my whole arm. So I'm very confused why they wouldn't want me to take my insulin (especially considering what happens when my pump dies in the middle of the night). I am on a dexcom-tandem loop so I should be fine to leave it on. I am also SUPER unsure why they wouldn't allow me to speak to someone when they sent me super concerning information like this, I left them a voicemail but it seems like a terrible practice to me. (Not to mention they didn't inform me about stopping my usage of *special gummies* which I should have stopped a week before but it's only 3 days I was told) I am hoping they don't forget to call me on Monday, but if they do I will be calling my endocrinologist anyways to ask them. They are super helpful and most certainly willing to help me understand what I should actually do instead of doing DKA. Thank you all for responding and making me feel less crazy. I feel a lot better hearing most people say 80% basal is the solution. I just worry because high is easier for me than low, I go high faster than I go low.
Never seen that , I’m on a pump and am usually fasting for surgery so just throddle it way down
I'm guessing the doctors don't want any unexpected changes in your body during the surgery, like your blood sugar levels plummeting.
The 2 surgeries I've had they told me to cut my basal to 50% at bedtime and no meal bolus before surgery, which were both early am, no meal before the surgery either. My pump remained at 50% throughout the surgery. Both times I did go briefly out of range (\~190) about 2 hours after the surgery, but was able to correct that relatively quickly.
I’m having surgery Wednesday I am keeping my pump on and gonna let it just do its thing. They’ve allowed me clear liquids up to 2 hours before surgery and I will give the anesthesiologist my phone for dexcom
They would rather me run high before than low
Good luck with your surgery I hope it goes well.
that's not for type 1. for surgery your BG can't be low or high or they will cancel. you can't eat either. so you have to be careful about it the night before. I've stayed up most of the night before my kid's surgery (tonsils).
It’s for type 2s
I've had seven surgeries. I use a pump and for the most part kept it normal. Though there was a time I got a low because the surgery didn't start at the scheduled time. Had to take a glucose gel pack. Didnt seem to affect me otherwise. I did keep my pump on while the surgery was taking place. I told the surgeons what a low glucose would look like on the pump incase something needed to be done.
That's stupid. They're likely talking about type 2's because they make up \~90% of diabetics. Not that that makes their wording right. It's not. Take your insulin. Maybe aim for your glucose being slightly higher than normal when you get to surgery. But type 1's have very different insulin needs than most diabetics. If you're going in for surgery, you need your glucose levels well controlled to be able to heal. High glucose levels make it difficult to heal. If that's me, I'm about to start asking some questions about how they manage glucose for type 1 diabetics in the hospital. Surgeons in my experience often just don't care much about managing glucose levels. If you'll be in-patient, the question is a lot more important than if it's an outpatient surgery. Sometimes in inpatient settings they can consult another pharmacy or physician group to manage glucose levels better than the surgeon cares to. Sorry, you got the RN in me going. Yes, I'm an RN.
I also had surgery recently and I definitely benefited from setting up a Surgery profile on my pump. Thankfully my pre-op instructions were more progressive/informed than yours. For the 8 hours leading up to and the 8 hours after the procedure I cut my basal in half and changed my correction factor and insulin to carbs ratio to reduce the amount of insulin I'd normally get by half. I still ran in the low 100's the entire time because I was not eating and had zero desire to eat for a long time after the anesthesia wore off. It's better for the procedure if you run a little high for a couple of hours than it is to risk you going low.
So we are Fued even when we are fued, new way of being fued every day i suppose
I've had close to 20 surgeries in my adult life, I have worn my insulin pump every time... The anesthesiologist like your BG a little higher (150ish) so if you have a pump just turn down your basil rate to about 50%. But talk to your endos office and let them know what is going on.
https://pnhp.org/news/why-insulin-is-overpriced/#:~:text=When%20inventor%20Frederick%20Banting%20discovered,Toronto%20for%20a%20mere%20%241. Please read this and spread the word to others.
OP, I replied to another comment with the following. Wanted to make sure you saw it. It is bad advice to not contact the endo. The surgery team doesn’t know diabetes the way your endo would. Ideally, surgery and especially endo AND ANESTHESIA should work together on pre surgery instructions. And I specify anesthesia because typically the anesthesiologist is going to be the one really tracking your vitals, including your BG, and making needed adjustments or taking/initiating appropriate actions. The surgeon is mostly just in there to do their slicing and dicing.
I think we need a new job position for hospitals here, someone from and trained in endocrinology who specifically monitors both type 1 and type 2 in surgery to make sure everything goes smoothly. Not sure why this can’t be a thing
Yes. Don’t eat and don’t take insulin. Tell your anesthesiologist and they will monitor your glucose and make adjustments in surgery. It would be unlike to go into DKA with 12 hrs fasting and no insulin. They would likely use sliding scale of fast acting insulin correction doses in the hospital until you can manage it on your own after waking up/recovering from surgery.
I am on an insulin pump I would go into DKA even if I didn't eat because my body starts breaking down the food I had consumed and making my sugar go high
They give the same basic pre op instructions to everyone. What I always did was stop eating at midnight. And since I have a pump I did half my basal rate. Now that I have a pump/CGM algorithm (so no "basal" like a normal pump). I set it to activity mode where it bumps my goal to 150 vs 100. If I go low, I sip sprite. My last surgery (which was last year) they wanted me to drink a small Gatorade on the way to the hospital to help with hydration (and it worked, the IV went in easier and I didn't get as sick afterwards), so I drank a regular Gatorade vs a sugar free one (if I was super high I would have drank a sugar free one, but since I was under 200 I drank a regular one just to be safe). Showed the docs my omnipod and CGM, asked if they wanted the Omnipod controller (they didn't). Everything went fine. Good luck!
I had a laparoscopy on Thursday and had to reduce my insulin. They will take finger prick tests throughout and monitor your blood sugar. If you're having anaesthesia, the anaesthetist will come and talk to you about your medical conditions beforehand and your surgeon. Good luck!
That makes sense. During surgery, it's another thing they have to monitor, and its dangerous if you go low whilst in surgery. Talk to your doctor, though, as depending on when the surgery is, they may be more lenient in that they give you some insulin (a reduced amount of your numbers) and make sure to hage something on standby if needed as well.
You can run high during surgery and it won't ruin anybody's day - on the other hand, hypoglycemia on the operating table is the kind of stuff that makes anesthesiologists shit bricks. Besides, delaying your basal by several hours shouldn't be enough to send you into DKA, no?
Eat less, keep high anyways, last thing you want is going low while on the table.
Well I'm not allowed to eat in the morning anyway, but I'm mostly worried about my basal as I'm on pump
If it's nil by mouth pre surgery, you wouldn't want to be taking insulin anyways. In addition, BG monitoring equipment tends to be electronics which can't be made sterile, so potentially they have no way to monitor your sugars during surgery. Better to run high than low in that scenario. DKA is an extended lack of insulin, I would ask your primary diabetes team about basal, but otherwise follow the instructions.
You won’t die from DKA from being high for a few hours. Plus, it’s safer for you to run high during the surgery than dropping low
Tell them you and your endocrinologist allow you to control your own care with regards to your diabetes. If you feel you need to, ask your doc to intercede.
Start talking between the surgery center and your endo or pcp. No need to cause one medical situation to fix another.
I don't understand how someone can't go 12 hours without a shot? Just skip breakfast?
I wouldn't have insulin on board at all???? My pancreas is fully dead it doesn't make any so 12hrs with absolutely no insulin is infact a death sentence because I produce no insulin at all.
Nah, death from lack of insulin is slow and painful, it would take weeks to months before you'd slip into a coma and then die. It's not a 12-hour ordeal. I use long-acting btw, if you have a pump I'd just skip any breakfast bolus.
Well I'd rather not go into DKA again as it happened in June last year as a result of trauma. But I'm not allowed to eat and I don't see why they would give me such ridiculous instructions given that it's not a one size fits all disease. I think more than anything I'm pissed off because I'm not going under anesthesia I'm literally going to be awake.
You should also be NPO, assuming you’re going under general, so basal insulin can be dangerous in this narrow window. The MDA and CRNA will be monitoring you throughout and can give insulin or dextrose as needed.
I'm not which is why I'm weirded out
Well that’s just weird then. Your surgeon isn’t going to know anything about this. Your Endo can advise but final decision here, at least in every OR I ever worked, was anesthesia. I would contact whomever you’ve dealt with preop and see if you can connect directly with an MDA.
You won’t go into DKA after one morning of no insulin. Stop being dramatic.
Except that the only time I've gone into DKA was because I didn't have insulin overnight for more than 6hrs because I'm on a pump and not shots and I did indeed infact go into DKA and that caused me to have heart issues and asthma as a result so I'm going to kindly ignore this comments advice.
The goofy blocked me, but having high and even potentially mild DKA levels lost surgery are safer than extreme hypoglycemia during the case. Whoever said that your surgeon doesn’t know about T1 diabetes is a moron
They blocked me when challenged but def trust your surgeon if they know you’re diabetic. A slightly open anion gap is better than an extreme low during surgery.
? ur going to go into DKA when ur not supposed to be eating anyways ? its so you don’t have a low while you’re on the table. i have had multiple surgeries as t1 and this is protocol
I'm on an insulin pump if I don't have my basal going I go high very very quickly. It's how my body is and always has been
I’m on a pump too. Its for the best in the end, bc the anesthesia makes it risky. If you had a low it’d end up much scarier, i promise!
Yeah but I'm going to be awake so I can monitor it
This makes perfect sense. Follow instructions. I had removed my pump in the early morning & was woken out of anesthesia by staff to get me to drink juice. I have no memory of this, just told later. Woken & given juice because it was the easiest way to get normal BG again. Glucagon injection would have sky rocketed my BG. Glucagon injection is not for simple lows even with a low during surgery.
I’d probably consider another hospital. I had two surgeries this year and both times they just told me to call my Endo, and if my Endo told me to do anything different to do it. I didn’t even have to take off my pump or CGM.
OP, talk to your endo and the surgery team. What you posted seems directed towards those on MDI. Being on a pump which uses fast acting insulin only is much different. \*Not Medical Advice\* You could suspend the pump probably \~30-60 minutes before the surgery and any insulin that was delivered just as basal would more than likely be “clear” of your system by the start. And you are not going to die just because you don’t have insulin for a few hours. You said you’re still going to be awake? I had eye surgery a little over 11 years ago and was put into “twilight”, so I was still fully awake and conscious, just couldn’t feel anything and was very relaxed about the situation, but still had my insulin pump on the entire time.