Postoperative Care

Intensive insulinization should be maintained in the postoperative ICU, especially in patients with increased risk of ketoacidosis. Problems can occur when ICU patients transfer to step-down units, where tight control to achieve 120 to 180 mg/dL values depends on SC insulin delivery, which is inherently more unstable. The principles of adequate basal coverage and reactive bolus insulin apply, although frequent adjustments remain necessary because of altered insulin pharmacokinetics associated with bed rest and decreased peripheral perfusion. Sick or postoperative patients also have dietary instability from tests, missed meals, and insulin therapy. Basal and bolus dosages must be flexible and reconsidered daily. Bolus dosages may need to be given immediately after a meal, when the nurse is certain the patient has eaten.

No definite rules can be made, but several generalizations may apply. Basal insulinization can be provided once in 24 hours or 2 or 3 doses of intermediate insulin. Glargine and detemir dosages provide good control 12 hours later, but intermediate insulin dosages could overlap, causing hypo-glycemic risk. Shorter-acting synthetic insulins are more safely used in the evening.

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