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I have cared for several of these patients; the first thing to recognize is that any patient who has a pump has already proven to be an educated, reliable and responsible manager of their disease process. I always listen to them in formulating my management of their diabetes.

1. Insulin pumps are not set on one basal rate..they are programmable to vary the basal rate throughout the day to regulate BG levels depending upon the anticipated/usual activity levels (including sleep time) and meal times. The patient's usual schedule is completely different on surgery day...generally much less active and with altered eating patterns, depending upon the time of day of the surgery, its length, complexity, etc.
2. The physical and surgical stress of surgery increases levels of circulating epinephrine, norepiphrine, glucagon, growth hormone and cortisol, all of which increase the BG.
3. Blood flow to the subcutaneous tissues can be dramatically reduced during general anesthesia, thereby altering the absorption of the insulin delivered by either a pump or SQ injection.
For these three reasons, I always have my patients use their pump as they see fit until arrival to the holding area, where they will disconnect them. All perioperative management of the diabetes is via IV administration of regular insulin to maintain BG levels in the 130-180 range. Checking glucose levels might be as frequent as every 30 minutes to achieve ideal management. In PACU, the patient resumes the pump when he/she feels it is appropriate to do so.

Source: The American College of Physicians Physicians' Information and Education Resourse: Perioperative Management of Diabetes Mellitus.

Sally Combest, M.D. (Please, not "MDA")

Sally Combest (Anesthesiologist/Nurse Anesthetist) at February 13, 2012 (2:53 pm)

I would also be interested if anyone have a policy there were willing to share.

K. Logan (OR Manager/Supervisor) at December 7, 2011 (3:27 pm)

My opinion based on experience---An insulin pump acts as a pancreas, secreting insulin at a basal rate preset by the patient's PCP. That basal rate should be allowed to continue as our pancreas does. Of course the FBS should be monitored throughout the case and additional regular insulin given if necessary. In my experience some patients go right through the procedure and never have an increase in the FBS. Others react to the surgical stress and have to be augmented with additional insulin.
I have worked in situations where MDA's were uncomfortable with these pumps and therefore just discontinued them because they did not understand the dynamics of the pump. Because of the lack of knowledge, they were too afraid to leave it on, which can really play havoc on a well controlled diabetic's blood sugar.
Each patient is different and input from their PCP could really be valuable in the care of these patients.
Most patients with insulin pumps really have an advanced knowledge of their disease and are more than willing to assist in their care. Just ask them.

D. Owens (Anesthesiologist/Nurse Anesthetist) at December 7, 2011 (3:22 pm)

It's really great that this forum exits. The downside is that misinformation is passed on taken for fact in some instances. On all these type questions past and future, the authority should address these issues. CMS thinks there is one. It would serve us all better if Outpatient Surgery Magazine sought out theses answers from the "authorities" instead of it being determination by opinion.

Just my opinion.

M. Brown (Administrator/Director/Manager/Owner/Exec. Officer) at December 7, 2011 (1:52 pm)

I would also be interested if anyone have a policy there were willing to share.

K. Logan (OR Manager/Supervisor) at December 7, 2011 (11:45 am)

Patients that have a pump,and are coming to our facility, must have medical clearance by the pump prescribing provider with a clear cut plan of care for either discontinuing or manipulation of the pump readings. The manipulation of the pump is usually done by the patient and overseen and documented by nursing and anesthesia providers.

patricia o. (Other) at December 7, 2011 (9:52 am)