Approach to Peri-operative Diabetes Management
description
Transcript of Approach to Peri-operative Diabetes Management
Approach to Peri-operative Diabetes Management
Ally P.H. PrebtaniAssociate Professor of Medicine
Internal Medicine, Endocrinology & Metabolism
McMaster University
Disclosure
SpeakerAd Board
Novo Nordisk Eli Lilly Sanofi Aventis
Objectives
PhysiologyWhy worry?New evidenceKey questions in managementGeneral principles of therapy and goalsDiabetes education & long-term issuesCases
Physiology
Insulin Resistance Catacholamines, cortisol, GH, glucagon Drugs
InsulinopeniaFluid shifts/Hemodynamics
Insulin absorptionFood intake
HypoglycemiaDecreased LOC
Gastroparesis
Why worry?
DehydrationInfectionWound HealingDKA/NKHCHypoglycemiaOther complications
CV > Hospital stay
EvidenceCV ICU - Intensive Insulin
Evidence
CV Surgery patients even without DM n=1548 12 mos
iv Insulin Tight control BS 4.4-6.1 post-op vs 10-11.1mM Significant decrease
Infection Mortality
8.0% vs 4.6% Ventilator Renal failure PRBC Critical polyneuropathy
Increased Hypoglycemia
Intensive Insulin in Critically Ill PatientsNEJM 2001; 345: 1359-67
Risk Reduction
42% (unadj)
32% (adj)
p < 0.04
Subgroup:
Largest effect in hospital due to ↓ deaths from sepsis (MOSF)
Medical ICU
Intensive Insulin in Medical ICUNEJM 2006; 354: 449-61
Prospective RCT, Single centren= 1200 Medical ICU, requiring ≥ 3 days
DM ~ 16% I: “Intensive glycemic control”
Insulin infusion when CBG > 6.1target CBG 4.4-6.1
Then conventional insulin when d/c ICU Randomly Assigned, non-blinded RN’s
C: Conventional Insulin infusion When CBG > 12.0 (target 10.0-11.1)
Intensive Insulin in Medical ICUNEJM 2006; 354: 449-61
Primary
Survival
A: All pts
•by day 3, possible increase mortality
•stat NS
ICU: 2.8% vs 3.9% p= 0.3
Hosp: 3.6% vs 4.0% p= 0.7
B: ≥ 3 days
Hosp: 52.5% vs 43.0% p=0.02
Intensive Insulin in Medical ICUNEJM 2006; 354: 449-61
Secondary:
All patients
(stat significant)
Subgroup analysis > 3 days
(stat significant)
Intensive Insulin in Medical ICUNEJM 2006; 354: 449-61
Other Results: Hypoglycemia:
More often intensive groupMore in those with CRI, liver failure & longer
stayAn independent risk factor for death
Less renal insufficiencyp < 0.05
Less bacteremiastat NS
Intensive Insulin in Medical ICUNEJM 2006; 354: 449-61
Unanswered question… Does insulin therapy actually cause
HARM if <3 daysAuthor explanations:
• More sick patients• More withdrawal of care (futility)• Why would 48 hours of insulin be harmful
whereas sustained insulin beneficial• Benefit require more time to realization• Prevention of complications
Types of InsulinInsulin Type Onset Peak Duration
Rapid-Acting(Lispro/Aspart)
10-15 min 60-90 min 4-5 h
Fast-Acting(Humlin R / Toronto)
0.5-1.0 h 2-4 h 5-8 h
Intermediate-Acting(N/NPH/Lente)
1-3 h 5-8 h Up to 18h
Long-Acting(Ultralente)
3-4 h 8-15 h 22-26 h
Extended Long-Acting(Glargine, Detemir)
90 min None 24 h
Premixed eg. 30 / 70(fast / intermediate)
Variable Variable Variable
General Principles
Morning OR if possibleHold own OHA & Insulin in am
decrease intermediate hs if Hx lows amConsider iv D5W infusion 75-100g/hr
unless BS >10 Minor
Frequent monitoring BS q1-2h call MD if BS outside of 5-10mM
tighter if CV Sx post-op
General Principles
Insulin for BS > 10 Type 1Type 1 all Major OR
iv Insulin if BS > 15 or Major ORHypoglycemia a no-no!NO sliding scales!
Goals of Glycemia
aim 5-10mM in General limited evidence small human and animal studies benefit > harm
4.5-6.0mM post-op CV Surgery/? other Major good evidence
Key Questions
1. Type of DM, Control & Complications
2. Treatment 3. Type & Length of OR and Type
of Anesthesia4. Expected time of NPO5. Morning BS
Other Investigations
CBC, Lytes, Renal, CoagsFBG, HbA1cECGCXR
(Lipids, Microalbumin, Liver, TSH)
IV Insulin Initiation
sc TDD/24/2 = iv U/hr to startTDD = 0.5-1.0U/kg if not on sc
insulin BMI, Type DM, Drugs
mix 50U Regular insulin in 250-500cc NS/D5W may concentrate 1:1 if volume an issue talk to nurse re: pump capabilities
iv Insulin
all Major surgeryall BS > 15mM
5-10 iv Insulin as calculated rate per hr10-14 increase iv Insulin by 0.5U/hr15-18 Lispro/Aspart sc 2U & inc iv Insulin
by 0.5U/hr if BS still increasing>18 Lispro/Aspart sc 3U & inc iv Insulin
by 0.5-1.0U/hr if BS still increasing
? OR if persistent BS > 15mM
sc Insulin
Minor onlyBS < 15
<8 1/2 of am intermediate sc Insulin (1/4 calculated TDD if new)
8-14 2/3 of am intermediate sc Insulin + Lispro/Aspart sc 2-3U
(1/3 calculated TDD if new)
What if the morning BS is low?
never want to go into OR hypoglycemic
< 5mM iv D50W 1/2-1 amp q20min till BS > 6mMDecrease iv rate by 0.5U/hr and hold for 1h if necessaryBS monitor q30-60minEnsure iv D5W running
Post-Op
Minor resume usual Tx if eating well may need short-acting insulin prn if
not given
Post-op
Major switch to usual once eating well & stable may need > sc insulin if on ++ iv Insulin
(look at amount iv needed) slowly increase sulfonylureas
Renal/liver fxn, po status
no metformin if contraindications NO sliding scales/supplements based on
TDD
Don’t Forget
Cardiopulmonary evaluation and mgmtOpportunity for DM education by teamFollow-up
Lipids, ASA, ACEI, BP ? Beta-blockers Medic-Alert, Vaccines Glucagon prn
Bottom Line
Pretty simpleAsk Key questionsDecreased ComplicationsMonitor BS frequentlyLow threshold InsulinAvoid HypoglycemiaAvoid sliding scalesDM education & Long-term Managment
Cases
1. 65yo man Type 2 DM going for CABG on insulin.
2. 17yo woman Type 1 DM for carpal tunnel release on Insulin.
3. 50yo woman Type 2 DM for cholycystectomy on Metformin.
Thank You