Diabetic Management Post-Laparotomy with Jejunostomy

Introduction to Diabetic Management

The American Diabetes Association recommends a basal-bolus insulin regimen with subcutaneous long-acting insulin once daily and ultra-rapid insulin analogue with each meal, adjusting doses based on carbohydrate intake and blood glucose monitoring, for a type 2 diabetic patient post-exploratory laparotomy with jejunostomy who is tolerating oral intake 1, 2

When converting from IV to subcutaneous insulin, the American College of Clinical Endocrinologists suggests giving half of the total 24-hour IV insulin dose as a single evening injection of slow-acting insulin, and dividing the remaining half of the 24-hour IV insulin dose by 3, giving this amount before each meal 1, 3
The first basal insulin injection should be administered immediately after stopping the IV infusion, ideally at 20:00 hours, as recommended by the American Association of Clinical Endocrinologists 1

The American Diabetes Association recommends blood glucose monitoring every 1-2 hours while NPO or receiving continuous enteral feeds, and pre-prandial testing before each oral meal to guide bolus insulin dosing 2, 5, 6
The target blood glucose range is 80-180 mg/dL (4.4-10.0 mmol/L) perioperatively, as recommended by the American College of Surgeons 5

The American Diabetes Association recommends administering 15-20 grams IV dextrose immediately for glucose <60 mg/dL (<3.3 mmol/L), even without symptoms, and giving 15-20 grams IV dextrose for glucose 60-70 mg/dL with symptoms 2, 5
The Endocrine Society suggests checking glucose every 15 minutes until >100 mg/dL after correction, and continuing dextrose infusion (D5W or D10W) until glucose stable ≤180 mg/dL for 24 hours 5

The American Association of Clinical Endocrinologists recommends checking for ketosis immediately in all T2D patients on insulin for pre-prandial glucose ≥16.5 mmol/L (≥3 g/L or ≥297 mg/dL), and giving 6 IU ultra-rapid analogue subcutaneously, ensuring good hydration, and rechecking glucose in 3 hours if ketonuria = 0 or ketonaemia <0.5 mmol/L 2, 6
The American College of Clinical Endocrinologists suggests transferring the patient to ICU for IV insulin infusion therapy if ketonuria ≥2+ or ketonaemia ≥1.5 mmol/L 6, 4

The American Diabetes Association recommends resuming previous oral antidiabetic agents at the same doses after 48 hours if renal function is adequate, and continuing ultra-rapid insulin initially, then tapering progressively until discontinued, for HbA1c <8% 3, 4
For HbA1c 8-9%, the American Association of Clinical Endocrinologists suggests resuming oral antidiabetics if no contraindications, stopping ultra-rapid insulin, but continuing basal (long-acting) insulin, and discharging the patient on usual OADs plus glargine (Lantus) with dose titration protocol 3, 4