Perioperative Management Diabetes Mellitus

Adrenal Insufficiency

William Harper, MD, FRCPC

Endocrinology & Metabolism

Assistant Professor of Medicine, McMaster University

Perioperative DM References

• An Update on Perioperative Management of Diabetes. Arch Int Med, 159:2405-2411, 1999.

• Inpatient Management of Adults with Diabetes. Diabetes Care. 18:870-878, 1995.

• Perioperative management of diabetes mellitus. www.uptodate.com, Dec 18, 2001.

BS > 11.1 mmol/L

Renal threshold for glycosuria (normal GFR)

Decreased WBC functionChemotaxsisPhagocytosis

Decreased Wound Healing

Goals of Perioperative DM Management

• “Avoid hypoglycemia and marked hyperglycemia”• Target BS: 7.0 - 11.0 mM• Avoid Hypoglycemia

• Precipitating arrhythmia or other cardiac events periop

• Inducing seizure, focal or cognitive defects periop– Difficult to identify as patients sedated during &

after surgery• Avoid Marked Hyperglycemia (BS > 11.1 mM)• Avoid DKA, HONC

Effects of Surgery on Glucose Control

• Raise BS:• Counter-regulatory hormones activated

» Glucagon» Cortisol» Catecholamines» GH

• Surgery, GA, postoperative stress/sepsis/etc.

• Lower BS:• Diminished caloric intake during & after surgery

• Therefore, perioperative BS levels difficult to predict!

Preoperative Assessment

Diabetic Hx/PE/Labs:• Glycemic control: last HbA1c, SMBG: FBS, 3AM• Pharmacologic Rx: OHA, Insulin• DM Complications:

– Nephropathy: Creatinine, K, HCO3, ECFv, etc.– Autonomic Neuropathy– Macrovascular (CAD): DM low-intermediate risk factor for a

perioperative cardiac event on all Indices

• Hypoglycemia: frequency/timing, awareness, severity

Surgery:• When NPO?• Timing and duration of surgery• Major or Minor procedure• Type of anesthesia (Local, Epidural, GA)

Preoperative Assessment

• Glycemic Control adjustments• Fasting & 3AM CPG:

• If running high (> 11-15 mM) needs modification of diabetic therapy to get better control so that not too hyperglycemic on morning of surgery.

• If running low or even “tight” (Tight control Target: 4-7 mM) consider reducing diabetic therapy to aim for perioperative target of 7-11.0 mM:

– 10-20% reduction in the intermediate or long-acting insulin taken night before surgery

– Increase the duration OHA(s) are held before surgery

Preoperative AssessmentWhen to hold OHA?

• Hold on AM of surgery!

• When to hold for longer (24-48h)?– FBS running low

– CRF: creat > 120-150uM (~ 50% decrease GFR)

» OHA still appropriate?

– Long-acting agents (chlorpropamide)

Insulin

Type Starts Peaks Duration

Humalog

NovoRapid

5-10 min 1-2 hrs 3.5 hrs

Regular 30 min 2-4 hrs 6-8 hrs

NPH

Lente

1-2 hrs 6-10 hrs 16-24 hrs

Ultralente 4-6 hrs 8-24 hrs 24-36 hrs

Glargine Immediately None Up to 24 hrs

Preoperative AssessmentWhen to hold Insulin?

• Hold their insulin dose on AM of surgery!

• The last dose of insulin day before surgery:

acB acL acD qhsBedtime NPH (+/-bids) N

NPH bid N N

30/70 bid 30/70 30/70

MDI (3 injections) H + N H N

MDI (>4 injections) H (+/-N) H H N

MDI (>4 injections) H + UL H H UL

CSII: Continue infusion until AM of surgery.

Day of Surgery

• DM patients should have surgery as early as possible in the AM to minimize disruption of their diabetic treatment regimen.

• CBG @ 7AM: RN to call MD with result as may have to modify your original orders.

• Re-check CBG in recovery: RN to call MD with result.

Glycemic control during Surgery

Dependent on: • Prior DM Rx regimen

• Surgery: Duration & Complexity

1) T2DM on Diet Rx +/- OHA

2) T1/T2DM on Insulin - Minor surgery

(< 2h, able to eat lunch)

3) T1/T2DM on Insulin - Major surgery

Perioperative Rx Options

1. Hold OHA

2. ½ AM insulin as NPH SC

3. IV insulin gttIV D5W 75-100 cc/h

Insulin IV gtt

• Add 50 U of Human regular insulin (Humulin R or Novolin Toronto) to 500cc D5W (1U/10cc).

• Flush & discard first 50cc.• Infuse insulin solution by IVAC (intravenous

infusion pump), piggybacked into D5W running at 100cc/h.

• Start insulin @ 0.9 U/h (9cc/h) or start at a rate dependent on patient’s insulin dose: IV insulin gtt rate = ( ½ TDD ) / 24

Insulin IV gtt

CPG q1h x 2, then q2h (if BS stable x 2-3 readings consider q4h):

Adjust Insulin IV infusion rate as per scale below:

<4.0 Call MD

4.1-5.0 0.7 U/h ( 7cc/h)

5.1-6.0 0.9 U/h ( 9cc/h)

6.1-7.0 1.2 U/h (12cc/h)

7.1-9.0 1.5 U/h (15cc/h)

9.1-11.0 2.0 U/h (20cc/h)

11.1-13.0 2.5 U/h (25cc/h)

13.1-15.0 3.0 U/h (30cc/h)

15.1-17.0 3.5 U/h (35cc/h)

17.1-20.0 4.0 U/h (40cc/h)

>20.1 Call MD

T2DM on Diet Rx +/- OHA

• Patient holds OHAs on AM of surgery

• CBG @ 7AM:

< 3.0 Consider postpone OR

3.1-4.0 IV D5W gtt @ 75-100 cc/h

4.1-11.0 Proceed with OR, no Rx necessary

> 11.1 IV insulin gtt

IV D5W gtt @ 75-100 cc/h

> 20.0 Check urine ketones, consider postpone OR

• Postop: CBG in recovery then bid• If not eating postop & BS > 11.1 mM:

• IV D5W 75-100 cc/h

• IV insulin gtt Insulin NPH/Lente SC q12h

• Allowed to eat postop: restart OHAs cautiously• Sulfonylureas: start only after eating is well established,

stepwise increase to preop dose

• Metformin: do NOT restart if postop ARF, CHF, liver dysfn.

• Thiazolidinediones: can exacerbate CHF

• Minor/Day Surgery:• Restart preop Rx regimen with evening meal

Postop: T2DM on Diet Rx +/- OHA

T1/T2DM on Insulin: What’s for Lunch?Hamilton Health Sciences DAILY MENU

Note: Menus must be filled out 24h in advance or else meal provision cannot be guaranteed. If your meal does not arrive please call 967-1111

BKFST[ ] 1/2 c cooked oatmeal with cinnamon, topped with 2 tsp. nuts[ ] 1/2 c low fat milk[ ] 1/2 grapefruit[ ] 1 slice whole wheat toast with 2 tsp. peanut butter or trans fat-free margarine[ ] 1 slice Pemeal bacon[ ] Non-caloric beverage (water, tea, coffee, etc.) LUNCH[ ] Peanut butter sandwich (2 Tbs. peanut butter, 1 Tbs. honey, 1/3 c seedless grapes cut in halves, 2 slices buttermilk white toast)[ ] Green salad (1 c lettuce, 4 tomato wedges, cucumber slices, 3 Tbs. small cooked shrimp, 2 tsp. vinaigrette dressing)[ ] 1 ginger snap[ ] Non-caloric beverage DINNER[ ] 2.5 oz. roasted turkey breast with no skin[ ] 1/4 c cranberry sauce[ ] 3/4 c mashed potatoes with 2 tsp. trans fat-free margarine[ ] 1/4 c baked sweet potato with 2 tsp. peanut butter or trans fat-free margarine[ ] 1/2 c fresh peas with 1 heaping tsp. trans fat-free margarine[ ] 1/8 of a pumpkin pie[ ] Non-caloric beverage

T1/T2DM on Insulin, Minor Surgery

• Patient holds all AM Insulin on day of Surgery

• CBG @ 7AM:

< 3.0 Consider postpone OR

3.1-11.0 Give ½ of total AM insulin dose as NPH SC

IV D5W gtt @ 75-100 cc/h

> 11.1 IV insulin gtt

IV D5W gtt @ 75-100 cc/h

> 20.0 Check urine ketones, consider postpone OR

Postop: T1/T2DM on Insulin, Minor Surgery

• CBG in recovery.• Patient eats lunch.• Short acting insulin (Regular/Analogue) SC with lunch:

• Give normal lunch time insulin dose• “Supplemental” dose if BS > 11.1 mM postop and dosen’t normally take

insulin at lunch time

• Had to Rx with IV insulin gtt due to hi BS preop?• Give normal lunch time dose of SC insulin as Regular NOT Analogue• If no normal lunch time dose: give 1/3 to 1/2 of AM intermediate acting

insulin dose as regular SC• Turn off IV insulin & D5W gtts 1h after SC insulin given with lunch

• Start back on normal regimen with evening insulin injection.

SC Insulin Supplemental Scale

CBG Action

< 4.0 Call MD

4.1-11.0 nil

11.1-15.0 Humalog 7U SC (0.1U/kg)

15.1-19.9 Humalog 10U SC (0.15 U/kg)

> 20.0 Call MD

T1DM/T2DM on Insulin: Major Surgery

• Patient holds all AM Insulin on day of Surgery

• CBG @ 7AM:< 3.0 Consider postpone OR

3.1-19.9 IV insulin gtt

IV D5W gtt @ 75-100 cc/h

> 20.0 Check urine ketones, consider postpone OR

Postop: T1/T2DM on Insulin, Major Surgery

• CBG: in recovery and then q1-2h• Continue on IV insulin & D5W gtts postop.• Switch over to SC insulin:

• When patient able to eat, preferably do switch in morning

• Overlap IV insulin gtt and SC insulin injection by 1-2h

• If BS not high then restart SC insulin at ½ to ¾ preop doses, then adjust accordingly

acB acL acD qhs Rx

22

(5R)

9 3.1

(O.J.)

15 acB N20 R10

acD N10 R5

20 15 7 8 acB N20 R10

acD N10 R5

22 17(RN calls)

acB N20 R10

Surgeon: ?Internal Medicine: ?Endocrinologist: ?

acB acL acD qhs Rx

22

(5R)

9 3.1

(O.J.)

15 acB N20 R10

acD N10 R5

20 15 7 8 acB N20 R10

acD N10 R5

22 17(RN calls)

acB N20 R10

Surgeon: Give 5 U Regular SC now

Internist: Increase acD N to 12 tonight and acB R to 12 tomorrow

Endocrine: Increase acD N to 12 start tonightDecrease acB N15 R7 starting tomorrow AMCheck 3AM BS tonight

DM Patient

Diet/OHA On Insulin

Minor Surgery Major Surgery

Preop BS > 11.1 mM

Hold OHA ½ AM insulinas NPH S.C. IV insulin gtt

D5W IV gtt

Summary: Periop DM Management

(Goal: BS 7.0-11.1 mM)

Evidence to support perioperative BS control?

DIGAMI• AMI, prior dx DM or BS > 11 mM• IV insulin gtt started @ 5 U/h• Titrated to keep BS 7-10.9 mM• Insulin IV > 24h MDI > 3 months• No in-hospital mortality benefit.• Rx Increased hospitalization by 1.8d• 0.5% reduction HbA1c @ 3 months• @ 1 year % on Insulin: 72% Rx Group 49% Cntrl Group• 1 year mort: ARR 7.5% NNT 13• 3.4 y mort: ARR 11% NNT 9

Evidence to support perioperative BS control?

Leuven, Belgium Study• ICU patients (63% CV Sx)• If BS > 6.1 mM: Rx with IV insulin gtt & TPN +/- tube feeds• Start IV insulin @ 2-4 U/h, titrated to BS 4.4-6.1 mM• Ave insulin dose: Rx group 3.0 U/h Cntrl group 1.4 U/h• Once out of ICU relaxed treatment goal to < 11.1 mM• Mortality in ICU: ARR 3.4% NNT 29• Mortality in-hospital: ARR 3.7% NNT 27• Greatest reduction in mortality was sepsis-related.• Insulin Rx reduced: bacteremia, ARF needing HD, need for PRBC,

critical illness polyneuropathy, duration of ventilation and length of stay in ICU

• To what extent were benefits nutrition related as opposed to insulin related?

Benefit of Perioperative Insulin

• DIGAMI– Reduce perioperative cardiac event risk?

• Leuven Study– Reduce sepsis– Reduce ICU associated morbidity & mortality

Perioperative Management of AI• If in doubt cover with perioperative steroids• 8 AM Pcortisol:

• > 552 nM excludes AI• < 138 nM suggests AI present (SEN 36%, SPEC~100%)

• Exogenous corticosteroid use:• replacement dose or greater for over a year

» Prednisone 7.5 mg/d» Hydrocortisone 20 mg/d

• Prednisone > 20 mg/d for > 1mos in past year

Diagnosis of AI

• Plasma ACTH, cortisol (time 0)• Short ACTH test (Pcortisol 30, 60 min):

– 250 ug: 1° AI (SEN 100%), 2° AI (SEN 90%)

– 1 ug: can pick-up 2° AI unless of recent onset (< 2 wk)

• ITT, Metyrapone testing

• If in doubt cover with perioperative steroids