Perioperative Management of Diabetes Mellitus

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Peri-operative Management of Diabetes Mellitus

• Christian Sinclair
• AIM Presentation
• December 18, 2002

2
Overview

• Pre-operative Evaluation
• Hospital Barriers to Glucose Control
• Common Errors in Glucose Management
• Glycemic Control
• Intervention Trials
• Hospital Utilization
• Recommendations
• References

3
Preoperative Evaluation

• DM is a major risk factor
• Silent ischemia, CAD
• Evaluate for end organ dysfunction
• Nephropathy, Autonomic Neuropathy
• CAD, PVD
• Baseline Glycemic Control
• Current Therapies Utilized
• Type of Surgery
• Type of Anesthesia

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Hospital Barriers

• Diabetes becomes secondary
• Infection
• Fever
• Glucocorticoids
• Surgery/Trauma
• Medical Stress
• Decreased physical activity
• Change in diet and drugs
• Patient has loss of control

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Common Errors

• Admission Orders
• Overly High Glycemic Targets
• Lack of Therapeutic Adjustment
• Overutilization of Sliding Scales
• Underutilization of Insulin Infusions

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Benefits of Glycemic Control
Reduced infection risk
Improved nutrient delivery
Improved immunoglobulin complement fixation
Improved leukocyte function
Less intravascular volume changes
Normalization of coagulation
Increased blood flow to wounds
Improved response of endothelium-dependent
vasodilation
Less electrolyte shifts
Improved oxygen delivery
Improved wound healing
Normalize GFR
Increased growth factor production
Elevated free fatty acids and cardiotoxicity
Less thrombotic complications
Normal skin fibroblast proliferation
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Interventional Trials

• DIGAMI
• Diabetes Insulin-Glucose Infusion in Acute MI
• 620 pts. with MI
• Randomized to
• Standard diabetic care
• Standard diabetic care and insulin-glucose IV for
  gt24 hrs. (Goal 126-196 mg/dl)
• ALSO recd 3 mos. of multi-dose insulin

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DIGAMI up to discharge

• Mean FSBG at 24 hours
• Control
• 211
• Standard plus insulin-glucose infusion
• 173
• Mean FSBG at discharge
• Control
• 162
• Standard plus insulin-glucose infusion
• 148

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DIGAMI 3.4 years of follow-up

• Deaths
• Control
• 138
• Standard plus insulin-glucose infusion
• 102 (ARR 28, P0.01) NNT 100/28 3.6

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N Engl J Med 11/8/01

• Van den Berghr et al.
• Belgium
• RCT of ventilated, ICU pts
• Randomized to
• Intensive insulin therapy (80-110 mg/dl)
• Conventional insulin (180-200 mg/dl)

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N Engl J Med 11/8/01

• Reason for admission
• 63 - Cardiac surgery (mostly CABG)
• 37 - Other surgery
• Prior diabetes
• Only 13 of patients (5 recd insulin)

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N Engl J Med 11/8/01

• Intensive Therapeutic Group
• Insulin infusion started if FSBG was greater than
  110
• Goal of 80-110 in the ICU
• Checked Q4
• Goal of 180-200 after transfer out of unit

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N Engl J Med 11/8/01

• Conventional Therapeutic Group
• Insulin infusion started if
• FSBG was greater than 215
• Goal of 180-200 in the ICU
• Checked Q4
• Goal of 180-200 after transfer out of unit
• In both groups, IV glucose was started and
  advanced to parenteral or enteral feeding ASAP

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N Engl J Med 11/8/01

• Study was designed to study 2500 patients to
  detect a mortality difference
• STOPPED EARLY!!

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N Engl J Med 11/8/01
P value
Intensive
Conventional
 
 
Mortality
lt0.04
4.6
8.0
Death during intensive care
lt0.005
10.6
20.2
Death among ICU gt 5 days
In-hospital death
0.01
7.2
10.9
All patients
0.01
16.8
26.3
ICU gt 5 days
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N Engl J Med 11/8/01
P value
Intensive
Conventional
 
 
Morbidity
0.01
11.4
15.7
Pts requiring gt14 d ICU
0.003
7.5
11.9
Pts requiring gt14 d Vent
0.04
9.0
12.3
Peak Creat gt 22.5
0.02
7.7
11.2
Peak PUN gt 54
0.007
4.8
8.2
HD or CVVHD
0.04
22.4
26.7
Peak Bilirubin gt 2
0.003
4.2
7.8
Septicemia
lt0.001
28.7
51.9
EMG ICU polyneuropathy
 
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Recommendations

• Individualize Therapy
• Development of hospital specific algorithims or
  protocols?
• Multi-disciplinary (MD, RN, dietician)
• Pain is the fifth vital sign..should blood
  glucose be the 6th

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Recommendations

• Diet
• ADA 1800, 2000 kcal
• Chance for education..
• Other comorbidities
• Obesity, hyperlipidemia, hypertension

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Recommendations

• Glucose Monitoring
• QAC QHS initially
• May decrease to BID if stable
• Chance for education..

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Recommendations

• Glucose Control
• Goal of 120-200
• Pre-op
• Early peri-op
• Late post-op
• Sliding scale
• Special considerations

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Preoperative phase

• Schedule surgery as early as possible to avoid
  interfering with regimen
• Education about hypo/hyperglycemic episodes
  (warning signs)
• Monitored every 1-2 hours before during and after
  surgery

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Preoperative phase

• Type 2 DM (diet controlled)
• No therapy needed perioperatively, may use
  regular/lispro SQ sliding scale PRN for FSBG gt200
• Type 2 DM (diet and oral tx)
• Hold DM meds after MN (including metformin)
• May use regular/lispro SSI PRN gt 200

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Preoperative phase

• Type 1/2 DM (with insulin)
• May continue SQ insulin for short simple
  procedures
• Switch from long acting (ultralente or lantus) to
  intermediate acting (NPH) 1-2 days prior to
  surgery (reduce hypogly)
• Reduce intermediate nighttime dose

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Preoperative phase

• Type 1/2 DM (with insulin)
• Short, early procedures
• Delay AM insulin until after surgery and before
  eating
• Missed breakfast
• ½ -2/3 of AM NPH dose
• Missed breakfast and lunch
• 1/3 - ½ of AM NPH dose, 1/3 of regular
• Pumps continue basal rate

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Preoperative phase

• Type 1/2 DM (with insulin)
• Late procedures
• 1/3-½ of usual intermediate insulin and D5W 100
  cc/hr
• Pumps continue basal rate
• Short acting sliding scale
• Long procedures (CABG, Xplant, etc.)
• Insulin infusion with glucose

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Late postoperative phase

• Hold metformin (CRI, hepatic insuff, CHF)
• Sulfonylureas stimulate insulin secretion and
  cause hypoglycemia
• Make sure eating has been established
• Subcutaneous insulin should be continued with D5
  supplement

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Special Considerations

• Glucocorticoid Therapy
• Mech of Hyperglycemia is multifactorial
• Incr. hepatic gluconeogenesis
• Inhibit glucose uptake in adipose
• Alteration of receptor and post-receptor fxn
• Leads to ketoacidosis
• High postprandial hyperglycemia
• Minimal elevation of fasting glucose
• May need to add or increase insulin

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References

• Jacober, SJ, Sowers, JR. An update on
  perioperative management of diabetes. Arch Intern
  Med 1999 1592405.
• Malmberg K. Prospective randomized study of
  intensive insulin treatment on long term survival
  after acute myocardial infarction in patients
  with diabetes mellitus. BMJ. 19973141512-1515.
• Metchick L. Inpatient Management of Diabetes
  Mellitus. Am J Med 2002 113317-323.