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Dr. Maria Wolfs
Assistant Professor
Endocrinology and Metabolism
St. Michaels Hospital
Diabetes for surgeons
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Outline
Background and evidence
Approach to the perioperative patient with DM The patient
The treatment
The surgery
Case discussions
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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 6575 yr
40% of those older than 80 yr
Umpierrez, GE et al. JCEM 2012;97:16-38
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Perioperative hyperglycemia
Case control studies
increased risk for adverse outcomes in patientsundergoing 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
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Perioperative hyperglycemia
postoperative infections
2.7 times higher in patients with glucose > 12.2mmol/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
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Reduced risk of infection
Infection
RR 0.41 (0.21- 0.71)
Murad, MH et al. JCEM 2012;97:49
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Glycemic targets in hospital
non-critically ill patients treated with insulin
premeal glucose of < 7.8 mmol/L random BG of
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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 therapyand minimize the likelihood of hypoglycemia [Grade D,
Consensus].
CDA 2008 Clinical Practice Guidelines
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Outline
Background and evidence
Approach to the perioperative patient with DM The patient
The treatment
The surgery
Case discussions
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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
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Case #2
29M MVC multiple fractures and head injury
Type 1 DM since age 4 Medications
Humalog 7-5-7
Lantus 12 units hs
On call to OR
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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
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Case #4
58F scheduled for total thyroidectomy for
multinodular goitre Type 2 DM for 10 years A1c 7.3%
Metformin 1g bid
Humulin Mix 25 60-0-40-0
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Case #5
78M POD 5 hip fracture ORIF
Type 2 diabetesMetformin 1000mg BID
Glyburide 10mg BID
Continuous NG feeds - swallowing concerns
BS on oral meds 14-18 mmol/L
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Approach to perioperative DM
The Patient
The Treatment The Surgery
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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
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The Treatment
Oral agents
Insulin Both
9 Basal coverage
9 Correction factor
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Oral anti-hyperglycemic drugs
Class Agents Concern Stop if:
Biguanides Metformin Lactic acidosis CHF, renal insufficiency
(eGFR
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Oral anti-hyperglycemic drugs
Class Agents Concern Stop if:
DPPIV
Inhibitors
Sitagliptin (Januvia)
Saxagliptin (Onglyza)
Linagliptin (Trajenta )
Renal impairment:
Sita eGFR
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Insulin 101
TDD = total daily dose of insulin
BASAL insulin = 40% of TDD
BOLUS insulin = 60% TDDBASAL 40%
BOLUS 60%
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Insulin 101
TDD = total daily dose of insulin
BASAL insulin = 40% of TDD BOLUS insulin = 60% TDD
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Insulin 101
TDD = total daily dose of insulin
BASAL insulin = 40% of TDD BOLUS insulin = 60% TDD
9 Basal coverage
9 Correction factor
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Insulin 101
BOLUS 60%
BASAL 40%
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Insulin pharmacokinetics
Humulin Novolin Sanofi Onset (h) Peak (h) Duration (h)
BOLUS HumalogRegular NovorapidToronto Apidra- 0.25-0.50.5 1-22-3 34-6
BASAL N
-
-
NPH
Levemir
-
-
-
Lantus
2
2
2
6-8
-
-
12-20
16-20
20-24MIXED Humalog
Mix 25
Novomix 30
Humulin
30/70
Novolin
30/70PUMP
9 Basal coverage9 Correction factor
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Insulin pharmacokinetics
Humulin Novolin Sanofi Onset (h) Peak (h) Duration (h)
BOLUS HumalogRegular NovorapidToronto Apidra- 0.25-0.50.5 1-22-3 34-6
BASAL N
-
-
NPH
Levemir
-
-
-
Lantus
2
2
2
6-8
-
-
12-20
16-20
20-24MIXED Humalog
Mix 25
Novomix
30
Humulin
30/70
Novolin
30/70PUMP
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Ensuring basal coverage
Usual DM regimen Basal coverage for AM of surgery
Oral agents only Hold until eating
Oral agents + bedtime N Usual dose of bedtime N
Oral agents + bedtime Lantus or Levemir Usual dose of bedtime Lantus or LevemirMixed insulin BID 20% of TDD as morning N
MDI with bedtime N Usual dose of bedtime N
MDI with am and bedtime N 70% of am NMDI with Lantus or Levemir Continue usual dose of Lantus or Levemir
Insulin pump Continue basal rate
Day surgery with anticipated eating soon
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Basal insulin
Humulin Novolin Sanofi Onset (h) Peak (h) Duration (h)
BASAL N-
-
NPHLevemir
-
--
Lantus
22
2
6-8-
-
12-2016-20
20-24
SubcutaneousN/NPH
40% AM 60% HS
25% q6h
33% q8h
Levemir/Lantus 100% HS Intravenous drip
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Basal insulin = 40% TDD
Home regimen TDD Basal (40% TDD)
Oral agents only Assume 30 units/day
Oral agents +
bedtime insulin
Assume 50 units/day
Mixed insulin BID Calculate daily dose
e.g. 40-0-20-0 = ___ units/dayMDI Calculate daily dose
e.g. Humalog 20-20-20-0 +
Humulin N 16-0-0-24 = ___ units/day
Unknown startingdose
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
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Basal insulin = 40% TDD
Home regimen TDD Basal (40% TDD)
Oral agents only Assume 30 units/day 12
Oral agents +
bedtime insulin
Assume 50 units/day 20
Mixed insulin BID Calculate daily dose
e.g. 40-0-20-0 = 60 units/day
24
MDI Calculate daily dose
e.g. Humalog 20-20-20-0 +
Humulin N 16-0-0-24 = 100 units/day
40
Unknown startingdose
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
7
40
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IV insulin infusion
Check for institutions pre-printed order set
1. Order insulin concentration 50 units of Humulin R in 500cc D5W
1 unit = 10 cc
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IV insulin infusion
Check for institutions 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, :)
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IV insulin infusion
Check for institutions 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, :)
3. Calculate basal rate
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Insulin 101 basal insulin
IV insulin drip rate = daily basal/24 hours
Home regimen TDD Basal IV insulin dripOral agents only Assume 30 units/day
Oral agents +
bedtime insulin
Assume 50 units/day 20 0.8 units/hour
Mixed insulin BID Calculate daily dosee.g. 40-0-20-0 = 60 units/day 24 1.0 units/hour
MDI Calculate daily dose
e.g. Humalog 20-20-20-0 +
Humulin N 16-0-0-24 = 100 units/day 40 1.5 units/hour
Unknown starting
dose
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
7.2
20
0. units/hour
0.8 units/hour
Start infusion at 1 unit/hr = 10 cc/hr Basal rate
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Start infusion at 1 unit/hr = 10 cc/hr
Capillary blood glucose check q1h
Basal rate
May not be feasiblein all settings
C Yu Jan 2012
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IV insulin infusion
Check for institutions 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, :)
3. Calculate basal rate4. Calculate correction factor
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IV insulin infusion
Check for institutions 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, :)
3. Calculate basal rate4. Calculate correction factor
9 Basal coverage9 Correction factor
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Correction factor
1 unit of insulin will lower BG by___mmol/L
= 100/TDD e.g. 70M home insulin regimen Humulin 30/70
30-0-20-0
TDD = ___ units
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Correction factor
1 unit of insulin will lower BG by___mmol/L
= 100/TDD e.g. 70M home insulin regimen Humulin 30/70
30-0-20-0
TDD = 50 units
CF = 100/TDD = 100/50 =___
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Correction factor
1 unit of insulin will lower BG by___mmol/L
= 100/TDD e.g. 70M home insulin regimen Humulin 30/70
30-0-20-0
TDD = 50 units
CF = 100/TDD = 100/50 = 2
1 unit of insulin will lower BG by 2 mmol/L
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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 6-5-8-0 + Glargine 14 hs
TDD = ___ units
CF = 100/TDD = 100/___ =___
1 unit of insulin will lower BG by___mmol/L
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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 6-5-8-0 + Glargine 14 hs
TDD = 33 units
CF = 100/TDD = 100/33 = 3
1 unit of insulin will lower BG by 3 mmol/L
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Correction factor (100/TDD)
Target a BG of 6 mmol/L
Start at 6+CFe.g. if TDD = 50 then CF = ___
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Correction factor (100/TDD)
Target a BG of 6 mmol/L
Start at 6+CFe.g. if TDD = 50 then CF = 2 then 6+2= ___
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Correction factor (100/TDD)
Target a BG of 6 mmol/L
Start at 6+CFe.g. if TDD = 50 then CF = 2 then 6+2=8
Blood glucose (mmol/L) Rapid insulin correction (units)
4.0-8.0 None
8.1-10.0 1
10.1-12.0 2
12.1-14.0 3
14.1-16.0 4
16.1-18.0 5
18.1-20.0 6> 20.1 7 and call MD
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Correction factor (100/TDD)
Target a BG of 6 mmol/L
Start at 6+CFe.g. if TDD = 33 then CF = ___ then 6+__=__
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Correction factor (100/TDD)
Target a BG of 6 mmol/L
Start at 6+CFe.g. if TDD = 33 then CF = 3 then 6+3=9
Blood glucose (mmol/L) Rapid insulin correction (units)
4.0-9.0 None
9.1-12.0 1
12.1-15.0 2
15.1-18.0 3
18.1-21.0 4
> 21.0 5 and call MD
Start infusion at 1 unit/hr = 10 cc/hr Basal rate
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/ /
Capillary blood glucose check q1h
If BG: Give additional bolus of:16.0 5 unit = 50 cc, call MD
If additional bolus required for 2 consecutive hours, increase infusionrate by 0.5 u/hr = 5 cc/hr
If no additional bolus required for 2 consecutive hours, decrease
capillary blood glucose check to q4h
asa ate
Correction factor
May need to adjust
May not be feasiblein all settings
C Yu Jan 2012
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The Surgery
Procedure
Timing Plan to eat
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The Surgery
Procedure
Timing
Plan to eat
Procedure DM regimen
Major cardiovascular IV insulin drip
Likely post-op ICU IV insulin drip
Day surgery Ensure basal coverage until eating
OR
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The Surgery
Procedure
Timing
Plan to eat
Timing DM regimen
Morning case
Afternoon Ensure adequate basal
Unknown Adequate basal or IV insulin drip
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The Surgery
Procedure
Timing Plan to eat
Plan to eat DM regimen
Same day Resume pre-op regimen once eating
POD1 Ensure adequate basal
POD2 or later Adequate basal or IV insulin drip
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Outline
Background and evidence
Approach to the perioperative patient with DM The patient
The treatment
The surgery
Case discussions
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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
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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%
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The Treatment
Oral agents
Insulin Both Metformin
Gliclazide
Humulin N
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Oral anti-hyperglycemic drugs
Class Agents Concern Stop if:
Biguinides Metformin Lactic acidosis CHF, renal insufficiency (eGFR
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The Surgery
Procedure
Timing Plan to eat
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Write orders
Basal coverage
Correction factor
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Ensuring basal coverage
Usual DM regimen Basal coverage for AM of surgery
Oral agents only Hold until eating
Oral agents + bedtime N Usual dose of bedtime N
Oral agents + bedtime Lantus or Levemir Usual dose of bedtime Lantus or Levemir
Mixed insulin BID 20% of TDD as morning N
MDI with bedtime N Usual dose of bedtime N
MDI with am and bedtime N 70% of am N
MDI with Lantus or Levemir Continue usual dose
Insulin pump Continue basal rate
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Correction factor (100/TDD)
Target a BG of 6 mmol/L
Start at 6+CFe.g. if TDD = 50 then CF = 2 then 6+2=8
Blood glucose (mmol/L) Rapid insulin correction (units)
4.0-8.0 None
8.1-10.0 1
10.1-12.0 2
12.1-14.0 3
14.1-16.0 4
16.1-18.0 5
18.1-20.0 6> 20.1 7 and call MD
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Case #2
29M MVC multiple fractures and head injury
Type 1 DM since age 4 Medications
Humalog 7-5-7
Lantus 12 units hs
On call to OR
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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 #
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The Treatment
Oral agents
Insulin Both
Humalog 7-5-7-0Lantus 12 hs
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The Surgery
Procedure
Timing Plan to eat
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Write orders
Basal coverage
Correction factor
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Ensuring basal coverage
Usual DM regimen Basal coverage for AM of surgery
Oral agents only Hold until eating
Oral agents + bedtime N Usual dose of bedtime N
Oral agents + bedtime Lantus or Levemir Usual dose of bedtime Lantus or Levemir
Mixed insulin BID 20% of TDD as morning N
MDI with bedtime N Usual dose of bedtime N
MDI with am and bedtime N 70% of am N
MDI with Lantus or Levemir Continue usual dose of Lantus or Levemir
Insulin pump Continue basal rate
Continue Lantus 12 units hs
l i li %
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Basal insulin = 40% TDD
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
Home regimen TDD Basal (40% TDD)
MDI Calculate daily dose
e.g. Humalog 7-5-7-0 +Lantus 0-0-0-12 = 31 units/day
31 x 0.40 = 12
C i f ( 00/TDD)
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Correction factor (100/TDD)
Target a BG of 6 mmol/L
Start at 6+CFe.g. if TDD = 33 then CF = 3 then 6+3=9
Blood glucose (mmol/L) Rapid insulin correction (units)
4.0-9.0 None
9.1-12.0 1
12.1-15.0 2
15.1-18.0 3
18.1-21.0 4
> 21.0 5 and call MD
C #3
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Case #3
75M POD2 bowel resection
Type 2 DM x 10 years Medications at home
Metformin 1000mg bid
Gliclazide MR 120mg
Sitagliptin 100mg
C #3
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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 13-18 mmol/L
Baseline eGFR >60ml/min Cr 95
Postop Cr 150
C #3
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Case #3
Restart metformin + sitagliptin
Restart metformin + gliclazide + sitagliptin Start sliding scale
Start IV insulin drip
Start basal insulin
Start basal insulin + correction factor
O l i h l i d
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Oral anti-hyperglycemic drugs
Class Agents Concern Stop if:
Biguinides Metformin Lactic acidosis CHF, renal insufficiency (eGFR
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Oral anti-hyperglycemic drugs
Class Agents Concern Stop if:
DPPIV
Inhibitors
Sitagliptin (Januvia)
Saxagliptin (Onglyza)Linagliptin (Trajenta )
Renal impairment:
Sita eGFR
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Basal insulin = 40% TDD
Home regimen TDD Basal (40% TDD)
Oral agents only Assume 30 units/day 12
Oral agents +
bedtime insulin
Assume 50 units/day
Mixed insulin BID Calculate daily dose
e.g. 40-0-20-0 = ___ units/dayMDI Calculate daily dose
e.g. Humalog 20-20-20-0 +
Humulin N 16-0-0-24 = ___ units/day
Unknown startingdose
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
W it d
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Write orders
Basal coverage
Correction factor
B l i li 12 it /d
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Basal insulin 12 units/day
Humulin Novolin Sanofi Onset (h) Peak (h) Duration (h)
BASAL N
--
NPH
Levemir-
-
-Lantus
2
22
6-8
--
12-20
16-2020-24
Subcutaneous
N/NPH 40% AM 60% HS 5 units AM 7 units HS
25% q6h 3 units q6h
33% q8h 4 units q8h
Levemir/Lantus
100% HS 12 units hs Intravenous drip 0.5 units/hour
C #3
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Case #3
Humulin N 5 units AM 7 units HS
Humalog correction factor 100/TDD100/30 = 3
Blood glucose (mmol/L) Rapid insulin correction (units)
4.0-9.0 None
9.1-12.0 1
12.1-15.0 2
15.1-18.0 3
18.1-21.0 4
> 21.0 5 and call MD
C #3
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Case #3
Required 5 units of Humalog correction
Can increase basal insulin by 4 units
Humulin N 7 units AM 9 units HS
Breakfast Lunch Dinner Bedtime
Blood sugar 12.4 10.1 13.6 8.9Humulin N 5 - - 7
Humalog
Correction
+2 +1 +2 0
C #3
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Case #3
Once eating:
If Cr back at baseline Restart oral medications
If Cr remains high
Add Bolus insulin
C #4
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Case #4
58F scheduled for total thyroidectomy for
multinodular goitre
Type 2 DM for 10 years A1c 7.3%
Metformin 1g bid
Humulin Mix 25 60-0-40-0
W it o d
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Write orders
Basal coverage
Correction factor
Ensuring basal coverage
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Ensuring basal coverage
Usual DM regimen Basal coverage for AM of surgery
Oral agents only Hold until eating
Oral agents + bedtime N Usual dose of bedtime N
Oral agents + bedtime Lantus or Levemir Usual dose of bedtime Lantus or Levemir
Mixed insulin BID 20% of TDD as morning N
MDI with bedtime N Usual dose of bedtime N
MDI with am and bedtime N 70% of am N
MDI with Lantus or Levemir Continue usual dose
Insulin pump Continue basal rate
e.g. Humalog Mix 25 60-0-40-0
TDD = ___ units/day20% TDD = ___ units N in am
Ensuring basal coverage
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Ensuring basal coverage
Usual DM regimen Basal coverage for AM of surgery
Oral agents only Hold until eating
Oral agents + bedtime N Usual dose of bedtime N
Oral agents + bedtime Lantus or Levemir Usual dose of bedtime Lantus or Levemir
Mixed insulin BID 20% of TDD as morning N
MDI with bedtime N Usual dose of bedtime N
MDI with am and bedtime N 70% of am N
MDI with Lantus or Levemir Continue usual dose
Insulin pump Continue basal rate
e.g. Humalog Mix 25 60-0-40-0
TDD = 100 units/day20% TDD = 20 units N in am
Correction factor (100/TDD)
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Correction factor (100/TDD)
TDD = 100 then CF = 1
Blood glucose (mmol/L) Rapid insulin correction (units)
4.0-8.0 None
8.1-10.0 2
10.1-12.0 412.1-14.0 6
14.1-16.0 8
16.1-18.0 10
18.1-20.0 12
> 20.1 14 and call MD
Case #5
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Case #5
78M POD 5 hip fracture ORIF
Type 2 diabetesMetformin 1000mg BID
Glyburide 10mg BID
Continuous NG feeds - swallowing concerns
BS on oral meds 14-18 mmol/L
Write orders
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Write orders
Basal coverage
Correction factor
Case #5
8/22/2019 Diabetes for Surgeons
87/89
Case #5
Start correction factor
estimate TDD of 30 unitsCF = 3
Blood glucose (mmol/L) Rapid insulin correction (units)
4.0-9.0 None
9.1-12.0 1
12.1-15.0 2
15.1-18.0 3
18.1-21.0 4
> 21.0 5 and call MD
Case #5
8/22/2019 Diabetes for Surgeons
88/89
Case #5
Required 11 units of Humalog correction/day
Can start basal insulin Humulin N 3-3-3-3 OR
Increase CF to 1:2
06:00 12:00 18:00 00:00
Blood sugar 15.3 15.7 16.1 13.5
Metformin +
Glyburide
9
9
9
9
9
9
9
9
Humalog
Correction
+3 +3 +3 +2
Outline
8/22/2019 Diabetes for Surgeons
89/89
Outline
Background and evidence
Approach to the perioperative patient with DM The patient
The treatment
The surgery
Case discussions
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