Perioperative Management of Diabetes Patients

Perioperative Management of Diabetes Patients

Learning Objectives To evaluate relevant risk factors associated with surgery in patientswith diabetes mellitus (DM) To identify strategies to achieve appropriate blood glucose (BG) targets perioperatively

Link Between Hyperglycemia and Poor Hospital Outcomes Metabolic stress response Stress hormones Glucose Insulin Immune dysfunction Infection dissemination FFA Ketones Lactate Cellular injury/apoptosis Inflammation Tissue damage Altered tissue/wound repair Acidosis Infarction/ischemia Reactive O 2 species Transcription factors Secondary mediators Clement S et al. Diabetes Care 2004;27(2). Prolonged hospital stay Disability Death

Insulin Needs in Healthy vs. Unwell Patients

Why is BG management during surgery important? A study evaluated the relationship between postoperative hyperglycemia and risk of infection. 100 patients with diabetes undergoing surgery, BG assessed on Day 1 post-op Good control: BG <220 mg/dl Poor control: >1 BG >220 mg/dl For patients with poor control: 3-fold increase in infection rate 6-fold increase in serious infection rate Pomposelli JJ, et al. JPEN J Parenter Enteral Nutr 1998;22:77-81.

Data on Cardiac Surgery Glucose control to target associated with reduced mortality and risk of deep sternal wound infections Multiple studies found positive correlation between post-op BG and both infection and mortality Furnary et al. Ann Thorac Surg 1999;67:352-62; Furnary et al. J Thorac Cardiovasc Surg 2003;125:1007-21; Golden et al. Diabetes Care 1999;22:1408-14.

Complications of Diabetes During Surgery, Anesthesia, and Postoperative Periods Metabolic control Diabetic ketoacidosis Nonketotic hyperosmolar states Hypoglycemia Hypokalemia Hyperkalemia CV complications Hypotension (related to autonomic diabetic neuropathy) Arrhythmia Postoperative myocardial infarction Other thrombotic phenomena Kidney involvement Acute kidney failure Volume overload Infections ADA. Therapy for Diabetes Mellitus and Related Disorders. 5th Edition. 2009.

Preoperative Patient Evaluation Metabolic control Glycemic control Nutritional status CV status Arterial hypertension Dyslipidemia Neurological status Gastrointestinal dysmotility Bladder dysfunction Renal function Blood urea nitrogen Serum creatinine Electrolytes Proteinuria ADA. Therapy for Diabetes Mellitus and Related Disorders. 5th Edition. 2009.

Risk Analysis: Surgical Risk Factors CV risk factors May or may not be diagnosed (e.g. silent ischemia) Obesity Chronic kidney disease Undiagnosed autonomic dysfunction Reduction in pulmonary function Meneghini LF. Cleve Clin J Med 2009;76:S53-9.

Insulin Therapy During Surgery Insulin should never be discontinued on insulin-treated patients, specifically basal insulin for T1 or T2DM. Insulin requirements can increase during major surgery with general anesthesia (e.g. coronary artery bypass graft surgery, or cardiopulmonary bypass). IV insulin provides the most flexibility and durability in maintaining desired glycemic control during prolonged surgical procedures. ADA. Therapy for Diabetes Mellitus and Related Disorders. 5th Edition. 2009.

Perioperative Insulin Procedure: General Guidelines Basal Patient will eat post-op Intermediate-acting insulin: ½-⅔ usual a.m. dose Long-acting insulin: continue usual dose p.m. prior to surgery Prandial/Nutritio nal When patient resumes eating: Restart prior dose of regular or rapidacting insulin Supplemental/Correctio nal Until patient resumes eating: Regular insulin: every 4-6 hrs Rapid-acting: every 4 hrs Clement S, et al. Diabetes Care 2004;27:553-91.

Perioperative Insulin Procedure: General Guidelines (cont d) Basal Prandial/Nutritio nal Patient will not eat (e.g. major surgery) Insulin drip Regular insulin: every 4-6 hrs Rapid-acting insulin: every 4 hrs Intermediate-acting insulin: ½ usual a.m. dose Long-acting insulin: usual daily dose N/A Supplemental/Correctio nal Until eating: Regular insulin: every 4-6 hrs Rapid-acting insulin: every 4 hrs Clement S, et al. Diabetes Care 2004;27:553-91.

Sample Protocol: Minor Surgical Procedures NPO 1. Withhold morning insulin or OAD 2. Measure capillary BG before procedure and every 2-4 hrs afterward 3. Give short- or fast-acting insulin SC every 2-4 hrs based on BG levels 4. Give usual afternoon dose If Breakfast Allowed 1. Give usual morning insulin or OAD 2. Measure BG before and after procedure 3. Give supplemental 4 units short- or fast-acting insulin SC if BG >250 mg/dl 4. Give usual afternoon dose ADA. Therapy for Diabetes Mellitus and Related Disorders. 5th Edition. 2009.

Postoperative Assessment and Management Metabolic: Insulin should be continued until metabolic condition is stable and patient can tolerate feeding. Transition plan should be implemented for patients on IV insulin. Postoperative evaluation of CV and renal function, and monitoring of surgical wound should be conducted. ADA. Therapy for Diabetes Mellitus and Related Disorders. 5th Edition. 2009.

Insulin Therapy in Perioperative Diabetic Patients (Major Surgery) Initial dose for bolus and drip: Initial blood glucose value (mg/dl) divided by 100, rounded to closest 0.5. Example: BG 236 236:100 = 2.36 rounded to 2.5 units, so: -Bolus IV: 2.5 units -Drip 2.5 units/hour Blood glucose examination every 1-2 hours Target: BG 150-200 or Δ BG/hour 50-100 (as long as BG >200) Check BG 1-2 hrs bedside BG <100 BG 100-149 BG <200 Δ BG >100 BG <60 BG 60-80 BG 81-99 Dose 50% BG <400 : +3-4 U BG 300-400: +1-2 U BG 200-299: +0.5-1 U Dose 50% Drip stopped Bolus D40% 1 f l Infus D5%/8 hrs Drip stopped Bolus D40% 0.5 f l Infus D5%/8 hrs Drip stopped + Infus D5%/8 hrs Check BG every 15 minutes GD 100 check after 1 hour and still 100 restart insulin drip with 50% of the last dose Stop D5% infus Perkeni, 2011.

Summary Management of patients with diabetes undergoing surgical procedures includes: Preoperative evaluation and analysis of risk factors Perioperative insulin management plan appropriate for the length of the procedure Postoperative assessment and insulin transition