Perioperative management for Diabetes Mellitus. Dr. Khor Hong Tar Consultant Endocrinologist NTFGH

Transcription

1 Perioperative management for Diabetes Mellitus Dr. Khor Hong Tar Consultant Endocrinologist NTFGH

2 Outline Physiology Why worry? Glycemic goal New evidence General principles

3 Physiology Altered oral intake NBM, enteral feeding, TPN Increase insulin resistance Catecholamines, GH, glucogon, cortisol Inflammatory cytokines: IL-6, TNF-α Insulinopenia Anesthetic agent Fluid shift/ altered hemodynamics Insulin absorption

4 Why worry? Dehydration DKA/HHS Hypoglycemia Poor wound healing Infection Other complications Cardiovascular event Prolonged hospital stay Golden, S. H et al. Perioperative glycemic control and the risk of infectious complications in a cohort of adults with diabetes. Diabetes Care, 22(9), Guvener, M et al. Perioperative hyperglycemia is a strong correlate of postoperative infection in type II diabetic patients after coronary artery bypass grafting. Endocr J, 49(5),

5 Glycemic goal 1 Perioperative glycemic profile?

6 New Evidence

7 Primary end-point: mortality

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11 CMAJ 2009;180(8):821-7

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13 Recommendation for glycemic target Surgical ICU: ADA (2015): mmol/l not recommend < 6.1 mmol/l (Grade A) CDA (2013): 8 10 mmol/l (Grade E, consensus) NHS (2012): 6 10 mmol/l Non-ICU: ADA: Premeal < 7.8 mmol/l Random < 10mmol/L (Grade C) CDA: Premeal: 5-8.0mmol/L Random < 10mmol/L

14 Glycemic goal 2 Preoperative A1c????? Halkos ME et al. Elevated preoperative hemoglobin A1c level is predictive of adverse events after coronary bypass surgery. J Thorac Cardiovasc Surg 2008; 136: hemoglobin A1c greater than 8.6% was associated with a 4-fold increase in mortality Patricia Underwood et al. Preoperative A1C and Clinical Outcomes in Patients With Diabetes Undergoing Major Noncardiac Surgical Procedures. Diabetes Care Volume 37, March 2014 chronic hyperglycemia (A1C >8%) is associated with poor surgical outcomes (longer hospital LOS)

15 General Principle Avoid hypoglycemia No subcutaneous insulin sliding scale alone Insulin infusion for ICU care Frequent BG monitoring hourly to 4 hourly Arrange for morning list T1DM: consult Diabetologist/Endocrinologist

16 No agreement on anything beyond this point!!!

17 Type of insulin Type Onset Peak Duration Fast-Acting Lispo/Aspart min min 4-5 h Intermediate- Acting Humalin R/Actrapid h 2-4 h 5-8 h Humalin N /Insulatard 1-3 h 5-8 h Up to 18h Long-Acting Glargine/Detemir 90 min None 24 h Premixed Mixtard 30/70 Variable Variable Variable

18 Oral hypoglycemic Agent Class Type Drug Insulin Secretagogues Sulphonylureas Tolbutamide, glimeperide, glipizide, gliclazide Meglitinides nateglinide Insulin Sensitizer Biguanides Metformin Alpha glucosidase inhibitor Glitazones Pioglitazone, Rosiglitazone Acarbose Incretins GLP-1 analogues Exenetide, Liraglutide DPPIV inhibitors Sitagliptin, Linagliptin Others SGLT-2 inhibitors Canaglifozin, Dapaglifozin

19 Best practice Major Surgery 1. Continue all usual OHGA & insulin regime day prior to surgery 2. Fast from midnight 3. Omit all OHGA & insulin morning of OT 4. Start IV insulin infusion with hourly BG monitor with dextrose saline 5. Keep IV insulin infusion for 24hrs and until good oral intake

20 Insulin Infusion Regime IV insulin infusion scale Alberti Regime

21 IV Insulin Infusion Scale IV insulin infusion scale: Dilution: regular insulin 50 units in 50mls saline Dextrose and potassium containing drip need to be infused concurrently Blood Glucose (mmol/l) > 20 6 Insulin Infusion Rate (unit/hr)

22 Alberti Regime Combine Insulin, dextrose and potassium to remove the risk of accidental insulin infusion without dextrose. The amount of insulin added to each bag is fixed and depends on the patients blood glucose level. Blood glucose (mmol/l) Insulin (unit) in 500ml 10% glucose and 0.15% potassium < > 20 20

23 Best practice Minor Surgery 1. Type 1: Cont. all basal & bolus insulin day prior surgery Fast from midnight. Cont. basal & omit bolus in the morning of OT. Start Sc insulin correction scale. Regular BG monitor 2hourly Resume usual Insulin regime once eating well Consider IV insulin if BG>15mmol/L

24 Best practice 2. Type 2 Cont all insulin (premixed/basal/basal+bolus) & OHGA day prior to surgery Fast from midnight In the morning of OT Insulin: start sc insulin correction scale with 2-4hly BG monitor Premixed: halve the morning dose Basal + Bolus: keep basal dose, omit bolus dose Basal only: keep basal dose

25 Best Practice In the morning of OT OHGA: start sc insulin correction scale with 2-4hly BG monitor SU/metiglinide: omit morning dose Metformin: continue (omit if radio-contrast study involved) Glitazone: continue Acarbose: omit morning dose Incretins: continue Consider IV insulin if BG>15mmol/L Resume usual Rx if eating well (resume metformin if favorable serum creatinine following radio-contrast study)>

26 Don t forget Cardiopulmonary evaluation and management Identified cardiovascular complications Opportunity for DM education by team

27 Take Home Message Target glucose: mmol/L Monitor BS frequently Avoid sliding scales alone Avoid hypoglycemia

28 References: American Diabetes Association. Standards of Medical Care in Diabetes 2015.Diabetes care January 2015 Volume 38, Supplement 1 Peri-operative Diabetes Management Guidelines. Australian Diabetes society July 2012 NHS diabetes guideline for the perioperative management of the adult patient with diabetes. Diabetic Medicine, January In-Hospital management of Diabetes. Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. Can J Diabetes 37 (2013) s77-s81.

29 Thank you