Patients using continuous subcutaneous insulin infusion, including hybrid closed-loop pump systems with continuous glucose monitoring, are increasingly encountered in the post-anesthesia care unit (PACU). Safe care requires early verification of device function, regular blood glucose checks, and clear criteria for whether to continue the pump or transition to insulin administered intravenously or subcutaneously.

On admission to the PACU, the team should obtain a focused handoff that includes the pump’s brand and model, basal profiles, most recent bolus, and whether the device is in manual or automated mode. The pump’s battery, reservoir volume, and infusion site should be checked, as well as any intraoperative adjustments such as basal suspension. The patient’s usual glucose targets and hypoglycemia awareness should be noted. If a caregiver manages the pump, their presence should be confirmed ^1–3.

Blood glucose should generally be maintained between 100 and 180 milligrams per deciliter. Point-of-care testing should be performed on arrival and repeated every one to two hours until the patient is eating and clinically stable. Data from continuous glucose monitoring can provide context but should not guide treatment decisions immediately after anesthesia, when perfusion and sensor lag may affect accuracy ^4,5.

The insulin pump may be continued if the patient is alert enough for self-management in the PACU, hemodynamically stable, normothermic, and not subject to contraindications such as magnetic resonance imaging. Basal insulin should usually remain unchanged, although persistent hypoglycemia may justify a temporary reduction, and hyperglycemia can be managed with a correction bolus via the pump if the patient or caregiver is competent and nausea has been controlled. The pump should be suspended if the patient is sedated, delirious, vomiting repeatedly, on vasopressors, or if the device malfunctions.

If switching to intravenous insulin, the infusion should begin while maintaining basal delivery for about an hour before discontinuing the pump. The same overlap should occur when transitioning back. Hypoglycemia should be treated promptly with intravenous dextrose, with reassessment after 10 to 15 minutes. In contrast, hyperglycemia can be treated through the pump or with insulin following a protocol. Persistent high glucose readings might warrant ketone testing and an evaluation of the infusion set ^5–11.

The infusion site should be positioned away from surgical fields, pressure points, or warming devices. Following transfers, staff should check for kinking, blood in the cannula, or dislodgment. Alarms should only be silenced after the cause has been resolved. All changes and interventions should be documented ^10–12.

Prior to transfer or discharge, the clinical team should confirm stable glucose values, intact device function, and adequate supplies. Antiemetics and a nutrition plan should be provided. Patients and caregivers should receive reminders about infusion site care, sick-day management, and emergency contacts. Follow-up is advisable if glucose control was difficult or if steroids are prescribed ^5,8. Overall, attentive preparation and meticulous clinical care can ensure safe and successful management of patients with insulin pumps in the PACU.

References

1. Randmaa, M., Engström, M., Swenne, C. L. & Mårtensson, G. The postoperative handover: a focus group interview study with nurse anaesthetists, anaesthesiologists and PACU nurses. BMJ Open 7, e015038 (2017). DOI: 10.1136/bmjopen-2016-015038
2. Improving Post Anesthesia Care Unit (PACU) Handoff by Implementing a Succinct Checklist. Anesthesia Patient Safety Foundation https://www.apsf.org/article/improving-post-anesthesia-care-unit-pacu-handoff-by-implementing-a-succinct-checklist/.
3. Crowley, K., Scanaill, P. Ó., Hermanides, J. & Buggy, D. J. Current practice in the perioperative management of patients with diabetes mellitus: a narrative review. Br J Anaesth 131, 242–252 (2023). DOI: 10.1016/j.bja.2023.02.039
4. Lynn Adams, T. L. J., Roe, T. M. F., Hoeksel, R. & Rodriguez, Y. Management of the Postoperative Patient with Glucose Dysregulation in Ambulatory Care Settings: A Policy Proposal. Journal of PeriAnesthesia Nursing 39, e17 (2024). DOI: 10.1016/j.jopan.2024.06.044
5. Dogra, P., Anastasopoulou, C. & Jialal, I. Diabetic Perioperative Management. in StatPearls (StatPearls Publishing, Treasure Island (FL), 2025).
6. Duggan, E. W., Carlson, K. & Umpierrez, G. E. Perioperative Hyperglycemia Management: An Update. Anesthesiology 126, 547–560 (2017). DOI: 10.1097/ALN.0000000000001515
7. Ononogbu, C. & Crider, N. Improving Glycemic Control Protocol in the Post Anesthesia Care Unit. The University of Utath Interprofessional QI Reports. DOI: 10.26051/D-RVAM-PG0Z.
8. Cosson, E. et al. Practical management of diabetes patients before, during and after surgery: A joint French diabetology and anaesthesiology position statement. Diabetes Metab 44, 200–216 (2018). DOI: 10.1016/j.diabet.2018.01.014
9. Sreedharan, R., Khanna, S. & Shaw, A. Perioperative glycemic management in adults presenting for elective cardiac and non-cardiac surgery. Perioperative Medicine 12, 13 (2023). DOI: 10.1186/s13741-023-00302-6
10. Boyle, M. E. et al. Guidelines for Application of Continuous Subcutaneous Insulin Infusion (Insulin Pump) Therapy in the Perioperative Period. J Diabetes Sci Technol 6, 184–190 (2012). DOI: 10.1177/193229681200600123
11. Boyle, M. E. et al. Insulin Pump Therapy in the Perioperative Period: A Review of Care after Implementation of Institutional Guidelines. J Diabetes Sci Technol 6, 1016–1021 (2012). DOI: 10.1177/193229681200600504
12. Berget, C., Messer, L. H. & Forlenza, G. P. A Clinical Overview of Insulin Pump Therapy for the Management of Diabetes: Past, Present, and Future of Intensive Therapy. Diabetes Spectr 32, 194–204 (2019). DOI: 10.2337/ds18-0091