Current Approach to Current Approach to

Peri-operative control of Peri-operative control of Blood Sugar Blood Sugar

Dr. Md. YunusDr. Md. YunusAdditional Professor & In Charge, Cardiac Additional Professor & In Charge, Cardiac Anesthesia division, NEIGRIHMS, Shillong Anesthesia division, NEIGRIHMS, Shillong

drmdyunus@hotmail.com

What are the diagnostic yardsticks What are the diagnostic yardsticks

for DM?for DM?

What is impaired fasting glycemia?What is impaired fasting glycemia?

A BS of 180 mg.dlA BS of 180 mg.dl-1-1=How many =How many

mmol.Lmmol.L-1-1??

If venous BS is 110 mg.dlIf venous BS is 110 mg.dl-1-1, what is , what is

capillary BS?capillary BS?

Reproducible demonstration of fasting Reproducible demonstration of fasting

hyperglycemia: FBS > 110 mg% (6.1 mmol Lhyperglycemia: FBS > 110 mg% (6.1 mmol L-1-1) )

(Serum/plasma sugar > 126 mg% [7 mmol L(Serum/plasma sugar > 126 mg% [7 mmol L-1-1, , OROR

A ‘casual’ (R) BS of > 180 mg% [10 mmol LA ‘casual’ (R) BS of > 180 mg% [10 mmol L-1-1], OR], OR

Oral GTT producing a result in the diabetic Oral GTT producing a result in the diabetic

range range

BS concentrations between 100 – 110 mg% (5.6-BS concentrations between 100 – 110 mg% (5.6-

6.1 mmol L6.1 mmol L-1-1) ) ‘impaired fasting glycemia’ ‘impaired fasting glycemia’

Diabetes (WHO criteria)

Diagnosed by a random plasma glucose Diagnosed by a random plasma glucose

>11.1mmol/l & a fasting >11.1mmol/l & a fasting

glucose>7.0mmol/lglucose>7.0mmol/l

What are the factors affecting the What are the factors affecting the peri-operative anesthetic peri-operative anesthetic

management of DM?management of DM?

Type of DMType of DM MedicationMedication End-organ changes End-organ changes Nature of surgery Nature of surgery Urgency of surgeryUrgency of surgery Level of glycemic control Level of glycemic control

Factors Adversely Affecting Diabetic Control Peri-operatively

AnxietyAnxiety StarvationStarvation Anaesthetic drugsAnaesthetic drugs InfectionInfection Metabolic response to traumaMetabolic response to trauma Diseases underlying need for Diseases underlying need for

surgerysurgery Other drugs e.g. steroidsOther drugs e.g. steroids

~2x~2x

Mort

ality

Rate

(%

) M

ort

ality

Rate

(%

)

Mean Glucose Value (mg/dL)Mean Glucose Value (mg/dL)

N=1826 ICU patients.Krinsley JS. Mayo Clin Proc. 2003;78:1471-1478.

0

5

10

15

20

25

30

35

40

45

80-99100-119120-139140-159160-179180-199200-249250-299>3000

5

10

15

20

25

30

35

40

45

0

5

10

15

20

25

30

35

40

45

Hyperglycemia & MortalityHyperglycemia & Mortalityin the Medical Intensive Care Unit in the Medical Intensive Care Unit

~4x~4x~3x~3x

CABG, coronary artery bypass graft.Furnary AP et al. J Thorac Cardiovasc Surg. 2003;125:1007-1021.

Cardiac-related mortality

Noncardiac-related mortality

Post-CABGPost-CABG

0

2

4

6

8

10

12

14

16

<150 150–175 175–200 200–225 225–250 >250

Average Postoperative Glucose (mg/dL)Average Postoperative Glucose (mg/dL)

Mort

ality

%M

ort

ality

%Mortality Increases With IncreasesMortality Increases With Increases

in Average BG Levelsin Average BG Levels

Mortality Risk Is Greater in Hyperglycemic Patients Without

History of Diabetes

111-111-145145

146-199146-199

200-300200-300

>300>300

Mean

BG

(m

g/d

L)

Mean

BG

(m

g/d

L)

Odds RatioOdds Ratio Odds RatioOdds Ratio

History Diabetes, History Diabetes, N= 62,868N= 62,868

No History Diabetes, No History Diabetes, N=152,910N=152,910

Falciglia M, et al. Crit Care Med. 2009;37:3001-3009.

Hyperglycemia Is Linked to Mortality Regardless of Diabetes

Status

* ≥200 mg/dL.Rady MY, et al. Mayo Clin Proc. 2005;80:1558-1567.Ainla MIT, et al. Diabet Med. 2005;22:1321-1325.

*

*

Mortality in Inpatients With

“New Hyperglycemia””

Umpierrez GE, et al. J Clin Endocrinol Metab. 2002;87:978-982.

In-h

osp

ital M

ort

ality

Rate

(%

)In

-hosp

ital M

ort

ality

Rate

(%

)

Newly Discovered

Hyperglycemia

Newly Discovered

Hyperglycemia

Patients With History of Diabetes

Patients With History of Diabetes

Patients With

Normoglycemia

Patients With

Normoglycemia

P <.01P <.01

Study Setting Population Clinical Outcome

Furnary, 1999 ICUDM undergoing open

heart surgery65% infection

Furnary, 2003 ICU DM undergoing CABG 57% mortality

Krinsley, 2004Medical/

surgical ICU Mixed, no Cardiac 29% mortality

Malmberg, 1995 CCU Mixed28% mortality

After 1 year

Van den Berghe, 2001*

Surgical ICU Mixed, with CABG 42% mortality

Lazar, 2004 OR and ICU CABG and DM60% A Fib post op

survival 2 year

Kitabchi AE, et al. Metabolism. 2008;57:116-120.

Benefits of Tight Glycemic Control: Observational Studies and Early

Intervention Trials

Glucose Control With IV Insulin Lowers Mortality Risk After Cardiac Surgery

10

8

6

4

0

Mort

ality

(%

)M

ort

ality

(%

)

87 88 89 90 91 92 93 94 98 99 00

YearYear

Patients with diabetes

Patients without diabetes

2

95 96 97 01

IV Insulin Protocol

Furnary AP, et al. Ann Thorac Surg. 1999;67:352-362.

Inzucchi SE. NEJM 2006;355;1903

Hyperglycemia & Acute Ilness

Hyperglycemia

Increases risks of

postoperative infections and

delirium

Prolonged hospital stay,

resource utilization

Increased renal

dysfunction and renal allograft

rejection in transplant

Adverse Effects of Hyperglycemia

Metabolic Responses to Surgery HormonalHormonal

– Secretion of stress Secretion of stress hormoneshormones

CortisolCortisol CatecholaminesCatecholamines GlucagonGlucagon Growth HormoneGrowth Hormone CytokinesCytokines

– Relative decrease Relative decrease in insulin secretionin insulin secretion

– Peripheral insulin Peripheral insulin resistanceresistance

MetabolicMetabolic– Increased Increased

gluconeogenesis gluconeogenesis and and glycogenolysisglycogenolysis

– HyperglycaemiaHyperglycaemia– LipolysisLipolysis– Protein breakdownProtein breakdown

Patients with diabetes deserve Patients with diabetes deserve

attentionattention

The Data for SurgeryThe Data for Surgery

Blood Glucose Level > 180 mg/dL(Hyperglycemia)

Increased Risk of Postoperative Complications

Importance of Perioperative Glycemic Control in General Surgery; Ann Surg, 2013:257Perioperative management of diabetes: Translating evidence into practice; CCJM, 2009

Blood Glucose Level < 70 mg/dL(Hypoglycemia)

Increased Risk of Mortality

Pre-operative Assessment

Most important step in the management of the Most important step in the management of the diabetic patientdiabetic patient

Involves a thorough history & physical examination Involves a thorough history & physical examination Review prior anaesthetic records to determine Review prior anaesthetic records to determine

whether there were any difficulties with intubation whether there were any difficulties with intubation or anaesthetics or anaesthetics

Lab investigationsLab investigations

– blood glucoseblood glucose - K+- K+

– BUNBUN - creatinine- creatinine

– ketonesketones - proteinuria- proteinuria

– HbA1c (to assess how well controlled diabetes HbA1c (to assess how well controlled diabetes is)is)

Pre-Operative Management

Admit as early as possible prior to surgeryAdmit as early as possible prior to surgery Avoid long-acting glucose lowering agentsAvoid long-acting glucose lowering agents

– chlorpropamidechlorpropamide –glibenclamide–glibenclamide– ultralente insulinsultralente insulins

Avoid metforminAvoid metformin Closely monitor blood glucose levelsClosely monitor blood glucose levels

– 2 hourly for Type 12 hourly for Type 1

– 4 hourly for type 2 4 hourly for type 2 Test urine every 8 hours for ketones Test urine every 8 hours for ketones Place first on morning operating list if possiblePlace first on morning operating list if possible Aim for a blood glucose of 5-10mmol/LAim for a blood glucose of 5-10mmol/L

CONTINUECONTINUE pre-hospital diabetes regimen if pre-hospital diabetes regimen if

appropriate, otherwise …appropriate, otherwise …

USEUSE insulininsulin as the treatment of choice as the treatment of choice

DO NOT DO NOT use sliding scale insulin aloneuse sliding scale insulin alone

DODO use use BASAL + BOLUS + CORRECTION BASAL + BOLUS + CORRECTION

insulin regimeninsulin regimen

AVOID AVOID hypoglycemiahypoglycemia

In-hospital Management In-hospital Management ChecklistChecklist

Clinical GuidelinesClinical Guidelines

“Patients need to have a blood glucose checked upon admission, & then every 1-2

hours while fasting”

“For blood glucose levels ≤ 70 mg/dL, institute must have the Treatment for

Hypoglycemia Protocol”

“Postoperatively, check blood glucose level upon arrival to unit, before meals, &

at bedtime or four times per day (if fasting)”

Create System to Support Clinical Create System to Support Clinical GuidelinesGuidelines

• How are we going to make this How are we going to make this happen?happen?

Mix of standard & non-standard Mix of standard & non-standard processesprocesses

Standard processes across specialties

Non-standard processes & resources, defined by each specialty

Does each area have the capacity & Does each area have the capacity & resources to check a blood glucose every resources to check a blood glucose every

2 hours on every diabetic patient?2 hours on every diabetic patient?

Challe

ng

eS

olu

tion

Lack Capacity

use glucometer

meters

Trained nursing

assistants to use meters

Lack Capacity

OR Lab could not support 2 hour testsOR Lab changed staffing

model using sweep

method

Lack Capacity

Lab staff on-call for as

needed tests

Ns trained to use meters

No change required

In the absence of routine In the absence of routine

insulin, sliding scale insulin insulin, sliding scale insulin

regimen (bolus insulin on a regimen (bolus insulin on a

prn basis) is purely prn basis) is purely

reactive rather than reactive rather than

proactiveproactive and allows for and allows for

hyperglycemia to occur hyperglycemia to occur

before responding before responding

BG (mmol/L) Bolus insulin (U)

<4 Call MD

4.1 – 10.0 0

10.1 – 13.0 2

13.1 – 16.0 4

16.1 – 19.0 6

>19.0 Call MD

Queale WS. et al. Arch Int Med 1997;157

Sliding Scale Alone is Inefficient

4.0

10.0

Breakfast Lunch Dinner Bedtime

BG (mmol/L) Bolus insulin (U)

< 4 Call MD

4.1 – 10.0 0

10.1 – 13.0 2

13.1 – 16.0 4

16.1 – 19.0 6

> 19.0 Call MD

6.0

Bolus insulin QID

14.0

6.0

16.5

3.0

Sliding Scale alone

What do you do?

What do you do?

What do you do?

What do you do?

+4 U

0 U 0 U

+6 U

QID: four times daily; SSI: sliding-scale insulin; BG: blood glucose

Sliding Scale Insulin Alone Results in Variable Glucose Control

BG (mmol/L)

**

**

** **

* P<0.001.Umpierrez GE, et al. Diabetes Care. 2007;30:2181-2186.

Mean BG Before Meals and at Bedtime During Basal-Bolus and SSI Therapy in

General Surgery Patients

Use BASAL + BOLUS + CORRECTION

In-hospital circumstances In-hospital circumstances may warrant temporarily may warrant temporarily

holdingholding other other antihyperglycemic antihyperglycemic

medications (medications (eg. eg. renal or renal or hepatic impairment)hepatic impairment)

Insulin = treatment of choiceInsulin = treatment of choice

BASAL + BASAL + BOLUS + BOLUS + CORRECTION CORRECTION

Insu

lin

BOLUS + CORRECTION

BASAL

Breakfast

Lunch

Dinner

BASAL + BOLUS + CORRECTION Results in Smoother Glycemic Control

4.0

10.0

Breakfast Lunch Dinner Bedtime

BG (mmol/L) Bolus insulin (U)

< 4 Call MD

4.1 – 10.0 0

10.1 – 13.0 2

13.1 – 16.0 4

16.1 – 19.0 6

> 19.0 Call MD

6.0

12.0

6.0

Correctional Insulin AC meals

What do you do?

What do you do?

What do you

do?

6+2 U

6+0 U

6U 6U

What do you do?6+0 U

6.0

ROUTINE Bolus insulin

Basal insuli

n

6U

18 U

Routine Basal

Create Clinical Guidelines Create Clinical Guidelines

““What do we need to do?”What do we need to do?”

Goal for Clinical GuidelinesGoal for Clinical Guidelines::

Establish a framework for the development of Establish a framework for the development of

processes & protocols to processes & protocols to maintain a random maintain a random

blood glucose (BG) < 180 mg/dL without blood glucose (BG) < 180 mg/dL without

increasing rates of symptomatic hypoglycemiaincreasing rates of symptomatic hypoglycemia, ,

or blood glucose levels <70 mg/dL in the adult or blood glucose levels <70 mg/dL in the adult

diabetic surgical patientdiabetic surgical patient

Kavanagh BP, McCowen KC. N Engl J Med. 2010;363:2540-2546.

Year Organization Patient PopulationTreatment Threshold

Target Glucose

LevelDefinition of

Hypoglycemia

Updated since

NICE-SUGAR Trial, 2009

2009 American Association of Clinical Endocrinologists and American Diabetes Association

ICU patients 180 140-180 <70 Yes

2009 Surviving Sepsis Campaign ICU patients 180 150 Not stated Yes

2009 Institute for Healthcare Improvement

ICU patients 180 <180 <40 Yes

2008 American Heart Association ICU patients with acute coronary syndromes

180 90-140 Not stated No

2007 European Society of Cardiology and European Association for the Study of Diabetes

ICU patients with cardiac disorders

Not stated “Strict” Not stated No

Guidelines From Professional Guidelines From Professional Organizations on the Management of Organizations on the Management of Glucose Levels in the ICUGlucose Levels in the ICU

Guidelines From Professional Guidelines From Professional Organizations on the Management of Organizations on the Management of

Glucose Levels in Noncritically Ill PatientsGlucose Levels in Noncritically Ill Patients

Year Organization Patient Population

Treatment Threshold

Target Definition of Hypoglycemia

Updated since NICE-SUGAR Trial, 2009

2009 AACE and ADA Consensus Statement

Non-critically ill patients

180 mg/dL

Premeal <140 mg/dL

<70 mg/dL(reassess treatment if <100 mg/dL)

Yes

2012 Endocrine Society Clinical Practice Guideline

Non-critically ill patients

180 mg/dL

Premeal <140 mg/dL

(reassess treatment if <100 mg/dL)

Yes

Moghissi ES, et al. Endocr Pract. 2009;15:353-369.Umpierrez GE, et al. J Clin Endocrinol Metabol. 2012;97:16-38.

Moghissi ES, et al. Endocr Pract. 2009;15:353-369.

AACE/ADA Recommended Target AACE/ADA Recommended Target Glucose Levels in ICU PatientsGlucose Levels in ICU Patients

ICU setting:ICU setting:– Starting threshold no higher than 180 mg/dLStarting threshold no higher than 180 mg/dL– Once IV insulin is started, the glucose level should be Once IV insulin is started, the glucose level should be

maintained between 140 and 180 mg/dL maintained between 140 and 180 mg/dL – Lower glucose targets (110-140 mg/dL) may be Lower glucose targets (110-140 mg/dL) may be

appropriate in selected patientsappropriate in selected patients– Targets <110 mg/dL or >180 mg/dL are not Targets <110 mg/dL or >180 mg/dL are not

recommendedrecommended

Recommended

140-180

Acceptable110-140

Not recommended

<110

Not recommended

>180

3535

AACE/ADA Recommended Target AACE/ADA Recommended Target Glucose Levels in Non-ICU PatientsGlucose Levels in Non-ICU Patients

Non–ICU setting:Non–ICU setting:– Premeal glucose targets <140 mg/dL Premeal glucose targets <140 mg/dL – Random BG <180 mg/dLRandom BG <180 mg/dL– To avoid hypoglycemia, reassess insulin regimen if To avoid hypoglycemia, reassess insulin regimen if

BG levels fall below 100 mg/dLBG levels fall below 100 mg/dL– Occasional patients may be maintained with a Occasional patients may be maintained with a

glucose range below and/or above these cut-points glucose range below and/or above these cut-points

Hypoglycemia = BG <70 mg/dLSevere hypoglycemia = BG <40 mg/dL

Moghissi ES, et al. Endocr Pract. 2009;15:353-369. 3636

Endocrine Society Endocrine Society Recommended Recommended Target Glucose Levels in Non-ICU Target Glucose Levels in Non-ICU

PatientsPatients

Blood glucose targets for the majority of patientsBlood glucose targets for the majority of patients

– Premeal: <140 mg/dLPremeal: <140 mg/dL

– Random: <180 mg/dLRandom: <180 mg/dL

Glycemic targets should be modified according to clinical statusGlycemic targets should be modified according to clinical status

– For patients who achieve and maintain glycemic control without For patients who achieve and maintain glycemic control without

hypoglycemia, a lower target range may be reasonablehypoglycemia, a lower target range may be reasonable

– For patients with terminal illness and/or with limited life expectancy or at For patients with terminal illness and/or with limited life expectancy or at

high risk for hypoglycemia, a higher target range (BG <200 mg/dl) may be high risk for hypoglycemia, a higher target range (BG <200 mg/dl) may be

reasonablereasonable

To avoid hypoglycemia, reassess and modify diabetes therapy when To avoid hypoglycemia, reassess and modify diabetes therapy when

BG is ≤100 mg/dLBG is ≤100 mg/dL

Modification of glucose-lowering treatment is usually necessary Modification of glucose-lowering treatment is usually necessary

when BG values are <70 mg/dLwhen BG values are <70 mg/dLUmpierrez GE, et al. J Clin Endocrinol Metabol. 2012;97:16-38. 3737

What are confounding factors in a diabetic for What are confounding factors in a diabetic for

emergency surgery?emergency surgery?

Do we have to wait for the DKA to settle before Do we have to wait for the DKA to settle before

taking up the patient?taking up the patient?

What are the indicators for going ahead with What are the indicators for going ahead with

surgery?surgery?

At what pH do we need sodabicarb correction; At what pH do we need sodabicarb correction;

what before that?what before that?

Role of insulin bolusRole of insulin bolus

Any alteration in monitoring?Any alteration in monitoring?

When to start KWhen to start K++, when glucose?, when glucose?

DM with uncontrolled BS for semi-em tomorrow; DM with uncontrolled BS for semi-em tomorrow;

are you game? If yes, how; if no, why not?are you game? If yes, how; if no, why not?

Confounding factors in a Confounding factors in a diabetic for emergency diabetic for emergency surgerysurgery

– Usually associated withUsually associated with infectious processinfectious process pronounced hyperglycemia, pronounced hyperglycemia,

dehydration and hypovolemiadehydration and hypovolemia metabolic decompensationmetabolic decompensation ± DKA± DKA

– Start aggressive treatment of DKAStart aggressive treatment of DKA complete resolution is usually not possible without complete resolution is usually not possible without

correction of the surgical problemcorrection of the surgical problem volume resuscitation (remember losses due to volume resuscitation (remember losses due to

precipitating cause)precipitating cause) partial correction of hyperglycemia, metabolic partial correction of hyperglycemia, metabolic

acidosis and ketosis acidosis and ketosis Consider bicarbonate if pH<6.9/7.0; bicarb conc. < Consider bicarbonate if pH<6.9/7.0; bicarb conc. <

10 mEq/L; hypotension unresponsive to IV fluids)10 mEq/L; hypotension unresponsive to IV fluids) insulin insulin bolusbolus & infusion as in the non surgical & infusion as in the non surgical

patient in DKApatient in DKA re-established urine output re-established urine output potassium supplementationpotassium supplementation phosphate supplementationphosphate supplementation start treatment of infectious process, if presentstart treatment of infectious process, if present

– Aim: Aim: definite trend towards metabolic definite trend towards metabolic improvementimprovement

– Monitor more oftenMonitor more often

Till thenTill then

Intra-op management?Intra-op management?

Post-op management?Post-op management?

What do persistent ketosis What do persistent ketosis with S. bicarb < 20 mEq/L & with S. bicarb < 20 mEq/L & normal BG indicate?normal BG indicate?

– Continue management of DKAContinue management of DKA

– Monitor more oftenMonitor more often

– There will usually be a rapid decrease There will usually be a rapid decrease in insulin requirements after surgery in insulin requirements after surgery metabolic control regainedmetabolic control regained need for careful and frequent monitoring need for careful and frequent monitoring

of BS and metabolic parametersof BS and metabolic parameters

– Persistent ketosis with S. bicarb < 20 Persistent ketosis with S. bicarb < 20 mEq/L & normal BG indicate need for mEq/L & normal BG indicate need for intracellular glucose and insulin for intracellular glucose and insulin for reversal of lipolysisreversal of lipolysis

Most of the poorly controlled Most of the poorly controlled diabetics can be controlled in diabetics can be controlled in about 12 h about 12 h – Start insulin infusionStart insulin infusion

– Check blood gases and capillary Check blood gases and capillary glucose hourlyglucose hourly

– Give sufficient glucose and potassium Give sufficient glucose and potassium

DM with uncontrolled BS DM with uncontrolled BS for semi-em tomorrowfor semi-em tomorrow

Diabetic ketoacidosis (DKA)Diabetic ketoacidosis (DKA) vs. vs. Hyperglycemic, hyperosmolar non Hyperglycemic, hyperosmolar non ketotic state (HHNS)ketotic state (HHNS)

Diagnosis of DKA: pHa < 7.3, HCO3 < 15 mmol.l-

1, BG > 250 mg.dl-1 Moderate

ketonemia and ketonuria

HHNS: pHa > 7.3 HCO3 > 20mmol.l-1

BG > 28mmol.l-1 (500 mg.dl-1)

Absent/minimal serum ketones

Urinary ketones -/minimal

Osmolality > 330 mOsm.kg-1

Ringer’s lactate?Ringer’s lactate?Bank blood?Bank blood?

Fluid and volume replacementFluid and volume replacement Lactate and is a gluconeogenic substrateLactate and is a gluconeogenic substrate

Ringer’s lactate = 28 meq/L Ringer’s lactate = 28 meq/L

Bank blood = variable amounts (anaerobic metabolism Bank blood = variable amounts (anaerobic metabolism

during storage) during storage)

Hepatic conversion to glucose Hepatic conversion to glucose aggravation of stress- aggravation of stress-

induced hyperglycemiainduced hyperglycemia

– Ringer’s lactate/Blood are NOT Ringer’s lactate/Blood are NOT

contraindicated contraindicated but but inappropriateinappropriate as these can as these can

confound the calculation of glucose load and insulin confound the calculation of glucose load and insulin

requirements requirements somewhatsomewhat

CONTINUECONTINUE pre-hospital diabetes regimen if pre-hospital diabetes regimen if

appropriate, otherwise …appropriate, otherwise …

USEUSE insulininsulin as the treatment of choice as the treatment of choice

DO NOT DO NOT use sliding scale insulin aloneuse sliding scale insulin alone

DODO use use BASAL + BOLUS + CORRECTION BASAL + BOLUS + CORRECTION

insulin regimeninsulin regimen

AVOID AVOID hypoglycemiahypoglycemia

Take Home Message Take Home Message In-hospital Management In-hospital Management

ChecklistChecklist

Take Home Message Take Home Message

In hospitalized patients In hospitalized patients

Proactive approach that includes Proactive approach that includes

basal, bolus, &correctionbasal, bolus, &correction

(supplemental) insulin(supplemental) insulin

sliding-scalesliding-scale insulin alone is not enough insulin alone is not enough

Uses Uses only short- or rapid-acting insulin only short- or rapid-acting insulin

1.1. NNon critically ill patients on critically ill patients

pre-meal BG targets should be pre-meal BG targets should be 5.0 to 8.0 5.0 to 8.0

mmol/L mmol/L

Random BG values Random BG values <10.0 mmol/L<10.0 mmol/L

2. M2. Medical/surgical critically ill edical/surgical critically ill 8.0-10.0 8.0-10.0

mmol/L mmol/L

2013

2013

Take Home Message Recommendations 1 & 2

A continuous IV insulin infusioninfusion

3. I3. Intraoperativentraoperative Glycemic levels between Glycemic levels between 5.5-10.05.5-10.0 mmol/L mmol/L for for

CABGCABG

A continuous A continuous IV IV insulin infusion protocol insulin infusion protocol administered by administered by

trained staff, trained staff, should be usedshould be used

4. Perioperative4. Perioperative glycemic glycemic 5.0-10.0 mmol/L 5.0-10.0 mmol/L for other surgical for other surgical

situationssituations

Appropriate protocol & trained staff to ensure safe & effective Appropriate protocol & trained staff to ensure safe & effective

implementation of therapy & to minimize the likelihood of implementation of therapy & to minimize the likelihood of

hypoglycemia hypoglycemia

2013

Take Home Message Take Home Message Recommendations 3 and 4Recommendations 3 and 4

5. 5. In hospitalized patients, hypoglycemia should In hospitalized patients, hypoglycemia should be avoided: be avoided:

– ProtocolsProtocols for hypoglycemia for hypoglycemia avoidanceavoidance

– RecognitionRecognition and and managementmanagement should be implemented should be implemented with with nurse nurse

– initiated treatmentinitiated treatment

– Glucagon for severe hypoglycemia when IV access is not Glucagon for severe hypoglycemia when IV access is not readily available readily available

– Patients at risk of hypoglycemia should have Patients at risk of hypoglycemia should have ready ready accessaccess to source of glucose (oral or IV) at all times to source of glucose (oral or IV) at all times

– particularly when NPO or during diagnostic procedures particularly when NPO or during diagnostic procedures

2013

Take Home Message Take Home Message Recommendation 5Recommendation 5

Patient Type Glucose Target (mmol/L)

Therapy of choice

Non-critically ill Fasting 5-8

Random <10

Pre-hospital regimen OR basal-bolus-correction

Critically ill 8-10 IV insulin infusion

CABG intraop 5.5-10 IV insulin infusion

Other periop 5-10 As appropriate

CABG = coronary artery bypass graft; IV = intravenous; Intraop = intraoperative; periop = perioperative

In-hospital Glycemic Targets

Thank YouThank You