ERAS AND DIABETES PERI-OPERATIVELY

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2 REFERENCES : Endotext.org Diabetes Manager : Perioperative Management of Diabetic Patients: New Controversies. Aldam, Levy & Hall BJA 2014 :Society of Ambulatory Anesthesia (SAMBA) Consensus Statement on Perioperative Blood Glucose Management in Diabetic Patients Undergoing Ambulatory Surgery

3 PRINCIPLES OF ERAS : The patient presents for surgery in the best possible condition : The patient is maintained in the best possible condition peri-operatively : The patient then recovers faster from their surgery.

4 ERAS AND DIABETES PERI-OPERATIVELY : The patient has well controlled diabetes HbA1c is less than 8 : All complications of diabetes are considered thoughtfully and checked if necessary. : Perioperatively the blood glucose is kept within a suitable range. : Hypoglycaemia is bad. : Hyperglycaemia is bad. : Glycaemic variability is bad. : Ketoacidosis is REALLY bad. : Hyperosmolar states are REALLY bad.

5 THE SAMBA ARTICLE : Take a focussed history what is the usual BGL, what is the hypo point, is the patient fairly self-sufficient or do they need guidance? : How do we manage oral anti-diabetic medication? : How do we manage insulin? : Is there a blood glucose level at which we should cancel surgery? : What is the optimal intra-operative BGL? : How do we maintain optimal BGL? : What is the optimal peri-operative glucose monitoring? : How should we identify and treat hypoglycaemia? : What discharge advice should we give?

6 THE BJA ARTICLE : Utility of HbA1c : Perioperative use of metformin : Optimal dose of peri-operative long acting insulin. : Ideal blood glucose range and measurement error.

7 UTILITY OF HBA1C : Now being used diagnostically : High values strongly associated with poor outcomes : HbA1c over 8 has been associated with quadrupled mortality after cardiac surgery.

8 PERIOPERATIVE USE OF METFORMIN : Traditionally stopped to avoid lactic acidosis. : No risk of hypoglycaemia : Continuation peri-operatively actually associated with better outcomes : Avoid combining with prolonged fasting and contrast media. : Peri-operative continuation now endorsed by Australian Prescriber

9 OPTIMAL DOSE OF PERIOPERATIVE LONG- ACTING INSULIN : Long-acting (basal) insulin should be continued. : A dose modification may be required. : Patients are eating less. : Patients are exercising less. : Stress hormones may elevate BGL. : 80% of patients given 80% of the long-acting insulin had satisfactory BGLs.

10 IDEAL BLOOD GLUCOSE RANGE : : May need to be higher if HbA1c high. : Above the hypo point. : Check your meter is working and accurate.

11 : Caloric excess : Poor food labelling : Poorly regulated advertising : Poorly regulated food industry

12 SOME STATISTICS : Excess food reaps food companies $20 billion per year profit in the US : The treatment of type 2 diabetes and obesity is costing the UK 1.5 million pounds per hour. : Most antidiabetic medication has not been shown to alter outcomes.

13 REVERSING THE TWIN CYCLES OF DIABETES : Bariatric surgery restores normal glucose metabolism within days for many people with type 2 diabetes : This reversal of diabetes depends upon the sudden and profound decrease in food intake; surgery is not required! : The hepatic insulin sensitivity normalises within days with reduced hepatic fat and normalisation of fasting glucose levels. : The beta cells improve over subsequent weeks with a fall in pancreatic fat.

14 TYPE 2 DIABETES : Starts as insulin resistance in muscle : ie - glucose intolerance : The logical treatment is carbohydrate restriction NOT more snacks : Dietary advice 80 years ago was to restrict carbohydrate : Dietary advice 40 years ago had to factor in the types of insulin used. : Actrapid lasts 6-8 hours, thus snacks were needed. : New ultra- rapid insulins may not even cover a meal with a high fat content, let alone need a snack as they wear off.

15 RELEVANCE OF THEORY TO ERAS : The liver improves within days of instituting a low carbohydrate diet : The pancreas improves over a few weeks. : A strict diet for a few weeks pre-operatively will improve fitness for surgery. : This is already being used by bariatric surgeons. : The reduced liver size makes all upper GI surgery more straightforward.

16 RETHINKING AND REFRAMING OBESITY Today s food environments exploit people s biological, psychological, social and economic vulnerabilities, making it easier for them to eat unhealthy foods. This reinforces preferences and demands for foods of poor nutritional quality, furthering the unhealthy food environments. Regulatory actions from governments and increased efforts from industry and civil society will be necessary to break these vicious cycles.

17 EMERGING EXAMPLES, ENTRENCHED BARRIERS, AND NEW THINKING. : No country to date has reversed its obesity epidemic : Compare to smoking. : Ban advertising of poor food. : Ban sponsorship deals. : Plain packaging.

18 SMART FOOD POLICIES FOR OBESITY PREVENTION : School settings : Economic instruments : Nutritional labelling

19 MOBILISATION OF PUBLIC SUPPORT : Media advocacy : Citizen protest and engagement : Development of a receptive political environment : Long term support and investment : Overhaul of current strategies : Reprioritisation of resources

20 MANAGEMENT OF OBESITY : Acknowledge the huge food industry investment in eating : Acknowledge the huge diet industry : Also the exercise industry : And the bariatric surgery industry : And of course the pharmaceutical industry!! : But if a patient asks how they can lower their HbA1c tell them to eat less, especially carbohydrate.

21 PEOPLE FRIENDLY CITIES : Public transport : Bicycle lanes : Walking attractive : Street vendors : Social interaction : Pedestrian thoroughfares : Speed limits (30km/hr)

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