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Home | Articles | Diabetes and Endocrinology | Switching from VRII

Switching from VRII

Last updated 3rd December 2020

Last updated on 17th November 2013 by Pam Young

Restarting Oral Hypoglycaemic Medication

  1. Restart oral hypoglycaemic agents at pre-operative doses once the patient is ready to eat and drink
  2. Be prepared to withhold or reduce sulphonylureas if the food intake is likely to be reduced 
  3. Withold Metformin if eGFR <30 ml/min.

Restarting SC Insulin if Already Established on Insulin

  1. Delay conversion to SC insulin until the patient is able to eat and drink without nausea or vomiting.
  2. Restart the normal pre-surgical regimen. Be prepared to adjust the doses because the insulin requirement may change as a result of postoperative stress, infection or altered food intake
  3. Consult the diabetes team if BG outside the acceptable range (4-12 mmol/L) or if a change in diabetes management is required.

For the Patient on Basal Bolus Insulin

  1. Rx first SC injection of fast acting insulin with breakfast or lunch and stop IV insulin and fluids 30 to 60 minutes later. Only restart before the evening meal if monitoring can be guaranteed. Do not convert to a SC regimen at bed time.
  2. If patient previously on long acting insulin eg Lantus or Levemir, this should have been continued.
  3. If the basal insulin was stopped in error, restart and continue the insulin infusion for further 2 hours before discontinuing.

For the Patient on a Twice Daily Fixed-Mix Regimen

  1. Reintroduce the insulin before breakfast or before the evening meal. Do not change to SC insulin at any other time. Maintain the VRII for 30 to 60 minutes after the SC insulin has been given.

For the Patient on an Insulin Pump

  1. Restart the pump at patient’s normal basal rate. Continue the VRII until the next meal bolus has been given. Do not restart the pump at bedtime. Click here for the section on Insulin Pumps.

Calculating SC Insulin Dose in Insulin-Naïve Patients

  1. Calculate the average hourly insulin dose by totalling the last 6 hours doses on the chart and dividing by 6 e.g. 12 units divide by 6 = 2 units/hour.
  2. Multiply by 20 (not 24 because risk of hypoglycaemia with the first dose) to get the total daily dose (TDD) insulin e.g. ~40 units.

Calculating a Basal Bolus (QDS) Regimen

  1. Give approx 50% of the TDD with the evening meal as long acting insulin and divide the remainder as rapid acting equally between pre-breakfast, pre-lunch and pre-evening meal.

Calculating a Twice Daily (BD) Regimen

  1. Give two thirds of the total daily dose at breakfast and the remaining third with the evening meal.

Links

  • Management of adults with diabetes undergoing surgery and elective procedures: improving standards. NHS Diabetes