In a patient with type 1 diabetes using an Omnipod insulin pump who is undergoing shoulder surgery, how should the pump be managed perioperatively?

Perioperative Management of Omnipod Insulin Pump for Shoulder Surgery

For shoulder surgery in a type 1 diabetes patient on Omnipod, continue the pump therapy perioperatively with specific precautions regarding pump site positioning, hourly glucose monitoring, and readiness to convert to IV insulin if glucose control deteriorates. 1

Decision Framework: Continue vs. Discontinue Pump

Shoulder surgery qualifies as minor to moderate surgery where pump continuation is appropriate. Discontinue the pump and switch to IV insulin only for:

• Major surgery
• Emergency surgery
• Abdominal procedures
• Operations causing significant ileus
• NPO status exceeding one meal
• Procedures requiring radiological screening (CT, MRI) 1

Since shoulder surgery doesn't meet these criteria, pump continuation is the preferred approach 1, 2.

Preoperative Preparation (Day Before Surgery)

Critical steps to complete 24 hours before surgery:

• Re-site the infusion set on the day before surgery to a location away from the surgical field (use thigh, not shoulder/upper arm area) 1
• Position the site away from potential diathermy placement and ensure accessibility for the anesthesiologist 1
• Perform overnight basal rate assessment to confirm adequate glucose control 1
• Monitor blood glucose after re-siting to ensure proper insulin absorption 1
• Verify patient has adequate pump supplies for entire hospital stay 1
• Notify the patient's diabetes pump team (may differ from hospital diabetes team) to confirm self-management competencies 1
• Obtain plastic infusion sets if needed 1

Day of Surgery Protocol

Preoperative Phase

• Check capillary glucose on arrival
• Document pump presence and settings in medical record 2
• Confirm infusion site location is appropriate for surgical positioning
• Verify pump is functioning properly

Intraoperative Management

Glucose monitoring:

• Check blood glucose hourly throughout the procedure 1
• Document pump status in anesthesia record 2

Thresholds for intervention:

• If glucose <4 mmol/L (72 mg/dL): Treat hypoglycemia per local protocol 1
• If recurrent hypoglycemia occurs: Disconnect pump immediately and start IV insulin infusion 1
• If glucose becomes uncontrolled: Switch to IV insulin infusion 1

Key technical considerations:

• Keep pump away from electrocautery/diathermy 1
• Protect pump from surgical field contamination
• Ensure pump remains accessible to anesthesia team

Postoperative Management

Immediate PACU period:

• Check capillary glucose hourly until patient is conscious and able to self-manage pump 1
• Continue hourly monitoring if patient cannot manage pump independently 1

First 24-48 hours:

• Instruct patient to increase testing frequency for 1-2 days post-surgery 1
• Target glucose 140-180 mg/dL (fasting <140 mg/dL, postprandial <180 mg/dL) 3
• Monitor for hyperglycemia related to surgical stress response 3

Conversion to IV Insulin (If Required)

If pump must be discontinued:

1. Start IV insulin infusion at least 30 minutes BEFORE disconnecting pump to prevent rapid hyperglycemia and ketosis 1
2. Use patient's basal rate as guide for IV insulin requirements (subcutaneous rates can be infused IV equivalently) 1
3. Monitor glucose hourly via capillary, venous, or arterial blood 1

When restarting pump:

• Run IV insulin alongside subcutaneous infusion for 2 hours with hourly glucose monitoring 1
• This establishes adequate subcutaneous depot before discontinuing IV 1

Common Pitfalls to Avoid

• Never expose pump to radiological screening (CT, MRI) - must disconnect per manufacturer recommendations 1
• Don't delay IV insulin in emergency situations requiring pump discontinuation 1
• Avoid placing infusion site near surgical field or where diathermy will be used 1
• Don't assume pump documentation - actively verify and document pump status at each perioperative phase 2
• Never skip the 30-minute overlap when transitioning between pump and IV insulin 1

Evidence Quality Note

The British Journal of Anaesthesia guideline 1 represents the highest quality evidence for this specific clinical scenario, supported by safety data from multiple institutional experiences 2, 4. The guideline demonstrates that no adverse events occurred when insulin pumps were continued appropriately during surgery 2, with mean glucose remaining in target range 1.