Diabetes for surgeons. Dr. Maria Wolfs Assistant Professor Endocrinology and Metabolism St. Michael s Hospital

Transcription

1 Diabetes for surgeons Dr. Maria Wolfs Assistant Professor Endocrinology and Metabolism St. Michael s Hospital

2 Outline Background and evidence Approach to the perioperative patient with DM The patient The treatment The surgery Case discussions

3 DM in hospitalized patients Approximately 1 in 4 patients admitted to the hospital has a known diagnosis of diabetes 30% of patients with diabetes require >2 hospitalizations in any given year High prevalence of diabetes elderly patients residents of long-term-care facilities up to one third of adults aged yr 40% of those older than 80 yr Umpierrez, GE et al. JCEM 2012;97:16-38

4 Perioperative hyperglycemia Case control studies increased risk for adverse outcomes in patients undergoing elective noncardiac surgery BG values > 11.1 mmol/l associated with prolonged hospital length of stay increased risk of postoperative complications wound infections and cardiac arrhythmias Umpierrez, GE et al. JCEM 2012;97:16-38

5 Perioperative hyperglycemia postoperative infections 2.7 times higher in patients with glucose > 12.2 mmol/liter than in those with glucose levels below 12.2 mmol/liter 3184 noncardiac general surgery patients perioperative glucose value above 8.3 mmol/liter associated with increased length of stay, hospital complications, and postoperative mortality Umpierrez, GE et al. JCEM 2012;97:16-38

6 Reduced risk of infection Infection RR 0.41 ( ) Murad, MH et al. JCEM 2012;97:49

7 Glycemic targets in hospital non-critically ill patients treated with insulin premeal glucose of < 7.8 mmol/l random BG of <10.0 mmol/liter avoid hypoglycemia (<3.9 mmol/liter) insulin dose should be reduced if glucose levels are between 3.9 mmol/liter and 5.6 mmol/l higher glucose ranges BG < 11.1 mmol/liter terminally ill patients patients with severe comorbidities Umpierrez, GE et al. JCEM 2012;97:16-38

8 Glycemic targets in hospital Provided that their medical conditions, dietary intake and glycemic control are acceptable, patients with diabetes should be maintained on their prehospitalization oral antihyperglycemic agents or insulin regimens [Grade D, Consensus]. Perioperative glycemic levels should be maintained between 5.0 and 11.0 mmol/l for most other surgical situations, with an appropriate protocol and trained staff to ensure the safe and effective implementation of this therapy and minimize the likelihood of hypoglycemia [Grade D, Consensus]. CDA 2008 Clinical Practice Guidelines

9 Outline Background and evidence Approach to the perioperative patient with DM The patient The treatment The surgery Case discussions

10 Case #1 52F scheduled for TAH tomorrow am Type 2 DM x 6 years, obesity Medications Metformin 1000mg bid Gliclazide MR 60mg am Humulin N 20u hs Atorvastatin 10mg hs Perindopril 8mg

11 Case #2 29M MVC multiple fractures and head injury Type 1 DM since age 4 Medications Humalog Lantus 12 units hs On call to OR

12 Case #3 75M POD2 bowel obstruction Type 2 DM x 10 years A1c 7.6% Medications at home Metformin 1000mg bid Gliclazide MR 120mg Sitagliptin 100mg

13 Case #4 58F scheduled for total thyroidectomy for multinodular goitre Type 2 DM for 10 years A1c 7.3% Metformin 1g bid Humulin Mix

14 Case #5 78M POD 5 hip fracture ORIF Type 2 diabetes Metformin 1000mg BID Glyburide 10mg BID Continuous NG feeds - swallowing concerns BS on oral meds mmol/l

15 Approach to perioperative DM The Patient The Treatment The Surgery

16 The Patient Type 1 or Type 2 Type 1 need insulin at all times!!! Glycemic control A1c, SMBG Diet NPO, DAT, clear fluids, NG feeds, TPN Activity level Medications Steroids Organ dysfunction/failure Ischemia

17 The Treatment Oral agents Insulin Both Basal coverage Correction factor

18 Oral anti-hyperglycemic drugs Class Agents Concern Stop if: Biguanides Metformin Lactic acidosis CHF, renal insufficiency (egfr <30ml/min), hypoperfusion, or chronic pulmonary disease, at risk of developing renal failure and lactic acidosis, iv contrast dye Sulfonylurea Gliclazide (Diamicron) Glyburide (Diabeta) Glimeperide (Amaryl) Repaglinide (Gluconorm) Nataglinide (Starlix) Hypoglycemia (Elderly, impaired renal function, poor nutritional intake) Hypoglycemia NPO, reduce dose if diet reduced NPO

19 Oral anti-hyperglycemic drugs Class Agents Concern Stop if: DPPIV Inhibitors Thiazolidined iones (TZD) Alphaglucosidase inhibitor Sitagliptin (Januvia) Saxagliptin (Onglyza) Linagliptin (Trajenta ) Pioglitazone (Actos) Rosiglitazone (Avandia) Renal impairment: Sita egfr <50 Saxa 2.5mg if egrf Lina approved in ESRD Causes CHF Rosi increased CV mortality Bladder CA Atypical fractures NPO CHF CAD Liver failure Acarbose GI upset NPO

20 Insulin 101 TDD = total daily dose of insulin BASAL insulin = 40% of TDD BOLUS insulin = 60% TDD BOLUS 60% BASAL 40%

21 Insulin 101 TDD = total daily dose of insulin BASAL insulin = 40% of TDD BOLUS insulin = 60% TDD

22 Insulin 101 TDD = total daily dose of insulin BASAL insulin = 40% of TDD BOLUS insulin = 60% TDD Basal coverage Correction factor

23 Insulin 101 BOLUS 60% BASAL 40%

24 Insulin pharmacokinetics BOLUS BASAL MIXED PUMP Humulin Novolin Sanofi Onset (h) Peak (h) Duration (h) Humalog Regular N - - Humalog Mix 25 Humulin 30/70 Novorapid Toronto NPH Levemir - Novomix 30 Novolin 30/70 Apidra Lantus Basal coverage Correction factor

25 Insulin pharmacokinetics BOLUS BASAL MIXED PUMP Humulin Novolin Sanofi Onset (h) Peak (h) Duration (h) Humalog Regular N - - Humalog Mix 25 Humulin 30/70 Novorapid Toronto NPH Levemir - Novomix 30 Novolin 30/70 Apidra Lantus

26 Ensuring basal coverage Day surgery with anticipated eating soon Usual DM regimen Oral agents only Oral agents + bedtime N Oral agents + bedtime Lantus or Levemir Mixed insulin BID MDI with bedtime N MDI with am and bedtime N MDI with Lantus or Levemir Insulin pump Basal coverage for AM of surgery Hold until eating Usual dose of bedtime N Usual dose of bedtime Lantus or Levemir 20% of TDD as morning N Usual dose of bedtime N 70% of am N Continue usual dose of Lantus or Levemir Continue basal rate

27 Basal insulin Humulin Novolin Sanofi Onset (h) Peak (h) Duration (h) BASAL N - - NPH Levemir Lantus Subcutaneous N/NPH 40% AM 60% HS 25% q6h 33% q8h Levemir/Lantus 100% HS Intravenous drip

28 Basal insulin = 40% TDD Home regimen TDD Basal (40% TDD) Oral agents only Oral agents + bedtime insulin Mixed insulin BID MDI Unknown starting dose Assume 30 units/day Assume 50 units/day Calculate daily dose e.g = units/day Calculate daily dose e.g. Humalog Humulin N = units/day Estimate based on weight (kg) Type 1 kg x 0.3 units/kg/day Type 2 kg x 0.5 units/kg/day e.g. 60 kg woman Type 1 units/day e.g. 100 kg man Type 2 units/day

29 Basal insulin = 40% TDD Home regimen TDD Basal (40% TDD) Oral agents only Assume 30 units/day 12 Oral agents + bedtime insulin Mixed insulin BID MDI Unknown starting dose Assume 50 units/day 20 Calculate daily dose e.g = 60 units/day Calculate daily dose e.g. Humalog Humulin N = 100 units/day Estimate based on weight (kg) Type 1 kg x 0.3 units/kg/day Type 2 kg x 0.5 units/kg/day e.g. 60 kg woman Type 1 18 units/day e.g. 100 kg man Type 2 50 units/day

30 IV insulin infusion Check for institution s pre-printed order set 1. Order insulin concentration 50 units of Humulin R in 500cc D5W 1 unit = 10 cc

31 IV insulin infusion Check for institution s pre-printed order set 1. Order insulin concentration 50 units of Humulin R in 500cc D5W 1 unit = 10 cc 2. Order IV fluids Glucose containing (D5W, ⅔:⅓)

32 IV insulin infusion Check for institution s pre-printed order set 1. Order insulin concentration 50 units of Humulin R in 500cc D5W 1 unit = 10 cc 2. Order IV fluids Glucose containing (D5W, ⅔:⅓) 3. Calculate basal rate

33 Insulin 101 basal insulin IV insulin drip rate = daily basal/24 hours Home regimen TDD Basal IV insulin drip Oral agents only Oral agents + bedtime insulin Mixed insulin BID MDI Unknown starting dose Assume 30 units/day Assume 50 units/day units/hour Calculate daily dose e.g = 60 units/day units/hour Calculate daily dose e.g. Humalog Humulin N = 100 units/day units/hour Estimate based on weight (kg) Type 1 kg x 0.3 units/kg/day Type 2 kg x 0.5 units/kg/day e.g. 60 kg woman Type 1 18 units/day e.g. 100 kg man Type 2 50 units/day units/hour 0.8 units/hour

34 Start infusion at 1 unit/hr = 10 cc/hr Capillary blood glucose check q1h Basal rate May not be feasible in all settings C Yu Jan 2012

35 IV insulin infusion Check for institution s pre-printed order set 1. Order insulin concentration 50 units of Humulin R in 500cc D5W 1 unit = 10 cc 2. Order IV fluids Glucose containing (D5W, ⅔:⅓) 3. Calculate basal rate 4. Calculate correction factor

36 IV insulin infusion Check for institution s pre-printed order set 1. Order insulin concentration 50 units of Humulin R in 500cc D5W 1 unit = 10 cc 2. Order IV fluids Glucose containing (D5W, ⅔:⅓) 3. Calculate basal rate 4. Calculate correction factor Basal coverage Correction factor

37 Correction factor 1 unit of insulin will lower BG by mmol/l = 100/TDD e.g. 70M home insulin regimen Humulin 30/ TDD = units

38 Correction factor 1 unit of insulin will lower BG by mmol/l = 100/TDD e.g. 70M home insulin regimen Humulin 30/ TDD = 50 units CF = 100/TDD = 100/50 =

39 Correction factor 1 unit of insulin will lower BG by mmol/l = 100/TDD e.g. 70M home insulin regimen Humulin 30/ TDD = 50 units CF = 100/TDD = 100/50 = 2 1 unit of insulin will lower BG by 2 mmol/l

40 Correction factor 1 unit of insulin will lower BG by mmol/l = 100/TDD e.g. 60 F home insulin regimen Humulin 30/70 Humalog Glargine 14 hs TDD = units CF = 100/TDD = 100/ = 1 unit of insulin will lower BG by mmol/l

41 Correction factor 1 unit of insulin will lower BG by mmol/l = 100/TDD e.g. 60 F home insulin regimen Humulin 30/70 Humalog Glargine 14 hs TDD = 33 units CF = 100/TDD = 100/33 = 3 1 unit of insulin will lower BG by 3 mmol/l

42 Correction factor (100/TDD) Target a BG of 6 mmol/l Start at 6+CF e.g. if TDD = 50 then CF =

43 Correction factor (100/TDD) Target a BG of 6 mmol/l Start at 6+CF e.g. if TDD = 50 then CF = 2 then 6+2=

44 Correction factor (100/TDD) Target a BG of 6 mmol/l Start at 6+CF e.g. if TDD = 50 then CF = 2 then 6+2=8 Blood glucose (mmol/l) Rapid insulin correction (units) None > and call MD

45 Correction factor (100/TDD) Target a BG of 6 mmol/l Start at 6+CF e.g. if TDD = 33 then CF = then 6+ =

46 Correction factor (100/TDD) Target a BG of 6 mmol/l Start at 6+CF e.g. if TDD = 33 then CF = 3 then 6+3=9 Blood glucose (mmol/l) Rapid insulin correction (units) None > and call MD

47 Start infusion at 1 unit/hr = 10 cc/hr Basal rate Capillary blood glucose check q1h May not be feasible If BG: Give additional bolus of: in all settings <4.0 Give ½ amp D5W, check BG in 15 min, call MD Continue at current rate unit = 10 cc and continue at current rate unit = 20 cc and continue at current rate Correction factor unit = 30 cc and continue at current rate unit = 40 cc and continue at current rate > unit = 50 cc, call MD If additional bolus required for 2 consecutive hours, increase infusion rate by 0.5 u/hr = 5 cc/hr May need to adjust If no additional bolus required for 2 consecutive hours, decrease capillary blood glucose check to q4h C Yu Jan 2012

48 The Surgery Procedure Timing Plan to eat

49 The Surgery Procedure Procedure Major cardiovascular Likely post-op ICU Day surgery OR <2 hours DM regimen IV insulin drip IV insulin drip Ensure basal coverage until eating Ensure basal coverage until eating Timing Plan to eat

50 The Surgery Procedure Timing Timing Morning case Afternoon Unknown DM regimen Ensure adequate basal Adequate basal or IV insulin drip Plan to eat

51 The Surgery Procedure Timing Plan to eat Plan to eat Same day POD1 POD2 or later DM regimen Resume pre-op regimen once eating Ensure adequate basal Adequate basal or IV insulin drip

52 Outline Background and evidence Approach to the perioperative patient with DM The patient The treatment The surgery Case discussions

53 Case #1 52F scheduled for TAH tomorrow am DM2 x 6 years, obesity Medications Metformin 1000mg bid Gliclazide MR 60mg am Humulin N 20u hs Atorvastatin 10mg hs Perindopril 8mg

54 The Patient Type 1 or Type 2 Type 1 need insulin at all times!!! Glycemic control A1c, SMBG Diet NPO, DAT, clear fluids, NG feeds, TPN Activity level Medications Steroids Organ dysfunction/failure Ischemia Type 2 A1c 7.8%

55 The Treatment Oral agents Insulin Both Metformin Gliclazide Humulin N

56 Oral anti-hyperglycemic drugs Class Agents Concern Stop if: Biguinides Metformin Lactic acidosis CHF, renal insufficiency (egfr <30ml/min), hypoperfusion, or chronic pulmonary disease, at risk of developing renal failure and lactic acidosis, iv contrast dye Sulfonylurea Gliclazide (Diamicron) Glyburide (Diabeta) Glimeperide (Amaryl) Repaglinide (Gluconorm) Nataglinide (Starlix) Hypoglycemia (Elderly, impaired renal function, poor nutritional intake Hypoglycemia NPO, reduce dose if diet reduced NPO

57 The Surgery Procedure Timing Plan to eat

58 Write orders Basal coverage Correction factor

59 Ensuring basal coverage Usual DM regimen Oral agents only Oral agents + bedtime N Oral agents + bedtime Lantus or Levemir Mixed insulin BID MDI with bedtime N MDI with am and bedtime N MDI with Lantus or Levemir Insulin pump Basal coverage for AM of surgery Hold until eating Usual dose of bedtime N Usual dose of bedtime Lantus or Levemir 20% of TDD as morning N Usual dose of bedtime N 70% of am N Continue usual dose Continue basal rate

60 Correction factor (100/TDD) Target a BG of 6 mmol/l Start at 6+CF e.g. if TDD = 50 then CF = 2 then 6+2=8 Blood glucose (mmol/l) Rapid insulin correction (units) None > and call MD

61 Case #2 29M MVC multiple fractures and head injury Type 1 DM since age 4 Medications Humalog Lantus 12 units hs On call to OR

62 The Patient Type 1 or Type 2 Type 1 need insulin at all times!!! Glycemic control A1c, SMBG Diet NPO, DAT, clear fluids, NG feeds, TPN Activity level Medications Steroids Organ dysfunction/failure Ischemia Type 1 A1c 8.5% Sedentary post #

63 The Treatment Oral agents Insulin Both Humalog Lantus 12 hs

64 The Surgery Procedure Timing Plan to eat

65 Write orders Basal coverage Correction factor

66 Ensuring basal coverage Usual DM regimen Oral agents only Oral agents + bedtime N Oral agents + bedtime Lantus or Levemir Mixed insulin BID MDI with bedtime N MDI with am and bedtime N MDI with Lantus or Levemir Insulin pump Basal coverage for AM of surgery Hold until eating Usual dose of bedtime N Usual dose of bedtime Lantus or Levemir 20% of TDD as morning N Usual dose of bedtime N 70% of am N Continue usual dose of Lantus or Levemir Continue basal rate Continue Lantus 12 units hs

67 Basal insulin = 40% TDD Home regimen TDD Basal (40% TDD) MDI Calculate daily dose e.g. Humalog Lantus = 31 units/day 31 x 0.40 = 12 Either calculate basal from TDD or use Lantus dose = 12 units/day Insulin drip rate = basal rate/24 hours 12 units/24 hours = 0.5 units/hour

68 Correction factor (100/TDD) Target a BG of 6 mmol/l Start at 6+CF e.g. if TDD = 33 then CF = 3 then 6+3=9 Blood glucose (mmol/l) Rapid insulin correction (units) None > and call MD

69 Case #3 75M POD2 bowel resection Type 2 DM x 10 years Medications at home Metformin 1000mg bid Gliclazide MR 120mg Sitagliptin 100mg

70 Case #3 75M POD2 bowel obstruction Type 2 DM x 10 years A1c 7.6% Medications at home Metformin 1000mg bid Gliclazide MR 120mg Sitagliptin 100mg Poor appetite post-op only minimal clear fluids Blood sugars mmol/l Baseline egfr >60ml/min Cr 95 Postop Cr 150

71 Case #3 Restart metformin + sitagliptin Restart metformin + gliclazide + sitagliptin Start sliding scale Start IV insulin drip Start basal insulin Start basal insulin + correction factor

72 Oral anti-hyperglycemic drugs Class Agents Concern Stop if: Biguinides Metformin Lactic acidosis CHF, renal insufficiency (egfr <30ml/min), hypoperfusion, or chronic pulmonary disease, at risk of developing renal failure and lactic acidosis, iv contrast dye Sulfonylurea Gliclazide (Diamicron) Glyburide (Diabeta) Glimeperide (Amaryl) Repaglinide (Gluconorm) Nataglinide (Starlix) Hypoglycemia (Elderly, impaired renal function, poor nutritional intake Hypoglycemia NPO, reduce dose if diet reduced NPO

73 Oral anti-hyperglycemic drugs Class Agents Concern Stop if: DPPIV Inhibitors Thiazolidine diones (TZD) Alphaglucosidase inhibitor Sitagliptin (Januvia) Saxagliptin (Onglyza) Linagliptin (Trajenta ) Pioglitazone (Actos) Rosiglitazone (Avandia) Renal impairment: Sita egfr <50 Saxa 2.5mg if egrf Lina approved in ESRD Causes CHF Rosi increased CV mortality Bladder CA Atypical fractures NPO CHF CAD Liver failure Acarbose GI upset NPO

74 Basal insulin = 40% TDD Home regimen TDD Basal (40% TDD) Oral agents only Assume 30 units/day 12 Oral agents + bedtime insulin Mixed insulin BID MDI Unknown starting dose Assume 50 units/day Calculate daily dose e.g = units/day Calculate daily dose e.g. Humalog Humulin N = units/day Estimate based on weight (kg) Type 1 kg x 0.3 units/kg/day Type 2 kg x 0.5 units/kg/day e.g. 60 kg woman Type 1 units/day e.g. 100 kg man Type 2 units/day

75 Write orders Basal coverage Correction factor

76 Basal insulin 12 units/day Humulin Novolin Sanofi Onset (h) Peak (h) Duration (h) BASAL N - - NPH Levemir Lantus Subcutaneous N/NPH 40% AM 60% HS 25% q6h 33% q8h Levemir/Lantus 100% HS Intravenous drip 5 units AM 7 units HS 3 units q6h 4 units q8h 12 units hs 0.5 units/hour

77 Case #3 Humulin N 5 units AM 7 units HS Humalog correction factor 100/TDD 100/30 = 3 Blood glucose (mmol/l) Rapid insulin correction (units) None > and call MD

78 Case #3 Breakfast Lunch Dinner Bedtime Blood sugar Humulin N Humalog Correction Required 5 units of Humalog correction Can increase basal insulin by 4 units Humulin N 7 units AM 9 units HS

79 Case #3 Once eating: If Cr back at baseline Restart oral medications If Cr remains high Add Bolus insulin

80 Case #4 58F scheduled for total thyroidectomy for multinodular goitre Type 2 DM for 10 years A1c 7.3% Metformin 1g bid Humulin Mix

81 Write orders Basal coverage Correction factor

82 Ensuring basal coverage Usual DM regimen Oral agents only Oral agents + bedtime N Oral agents + bedtime Lantus or Levemir Mixed insulin BID MDI with bedtime N MDI with am and bedtime N MDI with Lantus or Levemir Insulin pump Basal coverage for AM of surgery Hold until eating Usual dose of bedtime N Usual dose of bedtime Lantus or Levemir 20% of TDD as morning N Usual dose of bedtime N 70% of am N Continue usual dose Continue basal rate e.g. Humalog Mix TDD = units/day 20% TDD = units N in am

83 Ensuring basal coverage Usual DM regimen Oral agents only Oral agents + bedtime N Oral agents + bedtime Lantus or Levemir Mixed insulin BID MDI with bedtime N MDI with am and bedtime N MDI with Lantus or Levemir Insulin pump Basal coverage for AM of surgery Hold until eating Usual dose of bedtime N Usual dose of bedtime Lantus or Levemir 20% of TDD as morning N Usual dose of bedtime N 70% of am N Continue usual dose Continue basal rate e.g. Humalog Mix TDD = 100 units/day 20% TDD = 20 units N in am

84 Correction factor (100/TDD) TDD = 100 then CF = 1 Blood glucose (mmol/l) Rapid insulin correction (units) None > and call MD

85 Case #5 78M POD 5 hip fracture ORIF Type 2 diabetes Metformin 1000mg BID Glyburide 10mg BID Continuous NG feeds - swallowing concerns BS on oral meds mmol/l

86 Write orders Basal coverage Correction factor

87 Case #5 Start correction factor estimate TDD of 30 units CF = 3 Blood glucose (mmol/l) Rapid insulin correction (units) None > and call MD

88 Case #5 06:00 12:00 18:00 00:00 Blood sugar Metformin + Glyburide Humalog Correction Required 11 units of Humalog correction/day Can start basal insulin Humulin N OR Increase CF to 1:2

89 Outline Background and evidence Approach to the perioperative patient with DM The patient The treatment The surgery Case discussions