Perioperative management of diabetes – a piece of cake

Ada Cheung – Endocrine Registrar

Why is this important?

• • 25% of patients in the hospital have diabetes A large proportion of these patients will fast for surgery or a procedure

Perioperative complications

• • • Metabolic ▫ Hyperglycaemia  Stress hormones  Alteration in insulin/OHG ▫ Hypoglycaemia  Fasting  Alteration in insulin/OHG ▫ Lactic acidosis (major surgery or metformin) ▫ Electrolyte disturbance ▫ Dehydration Infection Cardiovascular morbidity and mortality

Good glycemic control improves

• • • • Deep sternal wound infection Mortality in patients undergoing CABG Hospital stay Infections

Hospital targets for glucose

• AACE and ADA guidelines ▫ Diabetes Care 2009;32:1119

6.1 – 10.0 mmol/L

• • • Principles of perioperative diabetes management • • Optimising glycaemic control reduces infection, wound and metabolic complications Ideally place patients first on the am list Monitoring – aim for BGL 6.1-10 ideally Fluids – patients on insulin should receive IV dextrose to minimise hypoglycaemia Insulin – patients on insulin require insulin even if fasting. Sliding scales are a guide & should be reviewed daily

Type 2 diabetes - principles

• • • • Minimise hypoglycemia ▫ Withhold OHG & short-acting insulin ▫ Fluids with dextrose if long-acting/basal insulin on board Minimise hyperglycaemia ▫ Use short-acting novorapid sliding scale 4/24 Monitor BGLs 2-4 hourly Notify HMO if BGL <4 or >15

John- T2DM diet controlled

• • 40 y man with T2DM 4 years diet alone Having elective vasectomy tomorrow ▫ Monitor BSLs 2 hrly ▫ Use Nsaline if IVT required ▫ Short acting insulin prn if BSL >10mmol/L

Oral hypoglycaemic agents

Generic Names

Metformin Gliclazide Gliclazide MR Glimepiride Glibenclamide Pioglitazone Sitagliptin Exenatide Acarbose

Trade names

Diabex Diaformin Diamicron Glyade Amaryl Daonil Actos Januvia Byetta Glucobay

Withhold

WH day of & 48 hrs post until renal fn stable WH day of surgery WH day of surgery WH day of surgery WH day of surgery

Lena – T2DM on OHG

• • • 65 year admitted with chest pain FI. Type 2 diabetes for 12 years, on metformin 1g bd, gliclazide MR 120mg mane, pioglitazone 45mg daily.

Fasting from midnight for coronary angiogram tomorrow

Lena – T2DM on OHG

• • • 65 year admitted with chest pain FI. Type 2 diabetes for 12 years, on metformin 1g bd, gliclazide MR 120mg mane, pioglitazone 45mg daily.

Fasting from midnight for coronary angiogram tomorrow ▫ WH metformin day prior to & then for 48 hrs post procedure. Reintroduce only when UEC normal.

▫ WH gliclazide+pioglitazone & restart when eating and drinking ▫ Monitor BGLs 2 hourly whilst fasting ▫ Fluids - Use Nsaline if IVT required ▫ Sliding scale novorapid 4/24 whilst fasting

Gloria – T2DM on insulin am surgery • • • 67 yo woman with T2DM for 15 yrs On Mixtard 30/70 40units mane, 30 units dinner and metformin 1g bd Elective varicose veins ligation tomorrow, fasting from midnight

Gloria – T2DM on insulin am surgery • • • 67 yo woman with T2DM for 15 yrs On Mixtard 30/70 40units mane, 30 units dinner and metformin 1g bd Elective varicose veins ligation tomorrow, fasting from midnight ▫ Withhold metformin day of surgery , restart 48 hrs post op if renal function at baseline ▫ Give normal insulin the night before ▫ ½ dose intermediate insulin in am i.e. Protaphane 20 units (not Mixtard which contains short-acting as well) ▫ Monitor BGLs 2 hourly whilst fasting ▫ Fluids with dextrose whilst fasting ▫ Sliding scale novorapid 4/24 whilst fasting

Type 1 diabetes - principles

• • • • Type 1 diabetics ALWAYS need basal insulin even if fasting ▫ i.e. Glargine (Lantus)/Detemir (Levemir)/ Protaphane/ Insulin infusion Minimise hyperglycaemia ▫ Use short-acting novorapid sliding scale whilst fasting Monitor BGLs 2-4 hourly Notify HMO if BGL <4 or >15 ▫ If BGL >15 - check for ketones (urine or capillary) • May require IV insulin infusion

Matthew – T1DM – qid insulin (basal bolus) am surgery • • • 27yo T1DM recently diagnosed Elective haemorrhoidectomy, fasting from midnight Basal bolus insulin regimen: ▫ Lantus 18 units nocte ▫ Novorapid 6 bfast, 6 lunch, 8 dinner ▫ Well controlled

Matthew – T1DM – qid insulin (basal bolus) • 27yo T1DM recently diagnosed • • Elective haemorrhoidectomy, fasting from midnight Basal bolus insulin regimen: ▫ Lantus 20 units nocte ▫ Novorapid 12 bfast, 16 lunch, 12 dinner ▫ Well controlled – HbA1c 6.9% ▫ Usual insulin the day before ▫ Always give long-acting/basal insulin (Lantus) even if fasting ▫ Fluids with dextrose whilst fasting ▫ Monitor BGLs 2 hourly ▫ Sliding scale novorapid 4/24 whilst fasting ▫ Resume usual insulin when eating and drinking

Matthew – T1DM – on insulin pump

• • • 27yo T1DM Dx 2 years ago Emergency appendicectomy on ETBS list On continuous subcutaneous insulin infusion (pump)

Matthew – T1DM – on insulin pump

• • • 27yo T1DM Dx 2 years ago Emergency appendicectomy on ETBS list On continuous subcutaneous insulin infusion (pump) • • • Change to IV insulin infusion Fluids with dextrose whilst fasting Intensive monitoring of BGLs (hourly on IV infusion)

Matthew – Post op

• • • • 2pm returns to ward Uneventful surgery – can eat and drink as tolerated 6pm feels hungry How should he be managed?

▫ Resume usual insulin ▫ Cease IV insulin infusion after overlap of 1-2 hrs with subcutaneous insulin

SUMMARY for patients with diabetes who are fasting

• Type 1 diabetics ALWAYS need basal insulin • Minimise hypoglycemia ▫ Fluids with dextrose if long-acting/basal insulin on board ▫ Withhold OHG & short-acting insulin • • • Minimise hyperglycaemia ▫ Use short-acting novorapid sliding scale 4/24 Monitor BGLs 2-4 hourly Notify HMO if BGL <4 or >15