Mary Ann Vann MD Beth Israel Deaconess Medical Center Boston, MA

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1 Mary Ann Vann MD Beth Israel Deaconess Medical Center Boston, MA Presentation Focus SAMBA Consensus Statement VANN

2 References Vann MA. Current Opinion in Anesthesiology. December Joshi GP, Chung F, Vann MA, et al. SAMBA Consensus Statement on Perioperative Blood Glucose Management in Diabetic Patients Undergoing Ambulatory Surgery. Anesth Analg December 2010 VANN 2011 Perioperative Goals Minimal disruption of normal life/routine Avoidance of Stress Reasons for Hyperglycemia Patient Anxiety Incorrect Instructions VANN

3 Preoperative Inquiries Diabetes Type Type 1: Absolute insulin deficiency Type 2: Insulin Resistance Relative Insulin Deficiency Produce basal insulin no Ketosis Multiple levels of treatment What is IDDM? Preoperative Inquiries Disease duration Adherence to medications Self-management skills Frequency of self-testing Active role in managing BG Complicated vs. simple regimens 3

4 Preoperative Inquiries Glycemic Control = HbA1c Standard of Care: every 3-6 months Standard for Control: < 7% Only 41-57% of adults reach this level Options Logbook Spot Glucose or Ask Why it matters Preoperative Inquiries: Hypoglycemia Definition: BG < 70 mg/dl Severe hypoglycemia: BG < 40 mg/dl Incidence and frequency BG at which symptoms occur Type of symptoms Risk factors: Old age Female gender 4

5 Hypoglycemia Unawareness Tightly controlled Type 1 diabetes Rare in Type 2 Absent or insufficient counter-regulatory hormones Hypoglycemia-associated autonomic failure Reversal with less tight control NOT same as: Upward shift in threshold for symptoms in type 2 Scheduling Does it make a difference? Disruption to normal life/routine Difficulties later in the day Provision of basal insulin NPH Insulins patient does not own 5

6 NPO Safety Avoid hypoglycemia Self-testing Travel with appropriate treatments gm CHO 8 oz juice, sugary drink Avoid glucose tablets and most gels Blood Glucose Testing Who? and When? Type 1 and 2 Arrival, PACU Every 1-2 hours Blood glucose values on day of surgery Maintain at normal level 6

7 Blood Glucose Testing Glucometers for point-of-care testing Benefits Cheap Easy to use Controversies FDA: 20% variance in reading Underestimates hypoglycemia Ambulatory patients Standards of Care Hospitalized Patients ADA Standards of Medical Care 2011 Diabetes Care January 2011 AACE, ADA Consensus Statement on Inpatient Glycemic Control Diabetes Care 2009 Proactive NOT Reactive No more Sliding Scales BG: mg/dl, never less than 110 7

8 Insulin Effect 11/13/2014 Physiologic Insulin Dosing Basal Insulin (Glargine, Detemir, CSII) Nutritional Insulin (Rapid-acting analogs) Correction Insulin (same as nutritional) Basal/Bolus Insulin Dosing versus Natural Insulin Secretion Rapid-acting Insulin Basal Insulin B L D HS Butz 8

9 Insulin Dosing: Day before Surgery No Change Unless frequent nocturnal or morning hypoglycemia.. Reduce by 20-30% Unless Type 2 Omit Reduce Insulin Dosing: Day of Surgery Patient to bring own Insulin Confirm exact type of insulin Administer patient s own insulin Potency Brand, analog 9

10 Insulin Dosing: Day of Surgery Basal Insulin: Covers basal needs while fasting How do I know its Basal insulin?? Should be only 50% of Total Daily Dose of Insulin Glargine or Detemir (not NPH) Insulin pump at sleep or sick day rate Give normal dose of basal insulin Insulin Dosing: Day of Surgery Intermediate-acting Insulins NPH and Fixed Combination Insulins Humulin 70/30 (NPH/Regular) Humalog Mix (Lispro protamine/lispro) Early morning case: Administer and do case Hold, do case, administer in PACU 10

11 Insulin Dosing: Adjustment Intermediate-acting insulin or long-acting peakless insulin solely Dosing interval, time of fast (predicted, actual) to determine fraction of intermediate acting insulin to give Dosing interval (hrs) Time of fast Dosing interval(hrs) Vann 2009 Insulin Dosing: Adjustment Example Patient takes 32 U of NPH twice daily He is expected to eat at 10am (3 hr fast) 12-3 = 3/4 [of 32 U] = 24 U of NPH 12 Remember NPH peak effect after 3 hours 11

12 Insulin Dosing: Day of Surgery Fixed combination Insulin: Adjustment 70/30: Only 70% is intermediate-acting Patient may not own NPH or Regular alone Humalog Mix: Lispro protamine NOT available alone Substitute NPH Calculate amount of NPH then adjust Correction Insulin Dosing Should be same type as nutritional: Rapidacting analogs Use of Subcutaneous Insulin Easy to administer (Pt, RN, MD) Avoids large and rapid swings in BG Replicates normal routine Reliable in hemodynamically stable Disadvantage: Stacking Abdomen > Arm > Leg 12

13 Correction Insulin Dosing Ask the patient Empirical formulas: 1-4U per 50mg/dl desired decrease Rule of 1800 Conservative, utilizes insulin sensitivity TDD: Total Daily Dose of Insulin 1800 TDD = mg/dl decrease in BG with each unit of rapid acting insulin given Insulin Dosing: Why Intravenous and Infusions NOT Appropriate Intravenous Regular Insulin: Duration 5-7 minutes Potentially harmful rapid swings in BG Infusion requirements: Protocols, training, frequent BG monitoring Basal insulin must be working prior to D/C of insulin infusion 13

14 Intraoperative Considerations Fluids: Dextrose load (250 cc D5= 12.5 gm) Nausea and vomiting Prophylaxis? Dexamethasone: 4 mg Pain Hypoglycemia D50: cc = gm Dextrose PACU Considerations BG Testing Administer Insulin: missed doses, correction Peak Effect of rapid acting insulin correction doses: 90 min Time to Discharge Able to tolerate fluids Instructions: responsible physician for DM Risks of hypoglycemia Reliable person 14

15 At Home Diabetes survival skills Postoperative phone call DKA can occur in hours SAMBA Consensus Statement Oral and non-insulin injectable medications Type 2 diabetics only Hypoglycemia rare: caution with sulfonylureas, meglitinides, injectables No evidence of metformin risk in ambulatory pts. Hold on day of surgery until food intake resumes 15

16 SAMBA Consensus Statement What blood glucose level is too high for surgery? Complications of hyperglycemia Dehydration, ketoacidosis, hyperosmolar state Adequacy of long term control Chronic hyperglycemia (poor control) Infection Delayed wound healing Risk of acute decreases in blood glucose Oxidative stress Increased perioperative morbidity and mortality SAMBA Consensus Statement Should an insulin naïve patient receive insulin on day of surgery? Hypoglycemia risk minimal Who should start it? When? What type? How much? Postoperative risks 16

17 Summary Minimize disruptions of normal routine Diabetes Type Matters Hypoglycemia: symptoms and treatment Some Basal Insulin is necessary Complex regimens = easy NPH/ Fixed combinations = harder Minimize pain, PONV Thank you!!! 17

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