Presentation on theme: "Diabetes Management: Different Treatments for Different Times"— Presentation transcript:
1 Diabetes Management: Different Treatments for Different Times Faith Pollock, APRN, CNS, CDE
2 Objectives Verbalize types of diabetes and diagnostic criteria. Discuss the management options for diabetes.Discuss the perioperative management of patients with diabetes.
3 Number of Americans with Diagnosed Diabetes, 1980-2009 From 1980 through 2009, the number of Americans with diabetes has more than tripled, from 5.6 million to 19.7 millionSource: Centers for Disease Control and Prevention, National Center for Health Statistics, Division of Health Interview Statistics, data from the National Health Interview SurveyReferenceCenters for Disease Control and Prevention. Number (in millions) of civilian, non-Institutionalized persons with diagnosed diabetes, United States, 1980–2009. Available at:3
4 New Cases of Diagnosed Diabetes About 1.9 million people ages 20 years or older were newly diagnosed with diabetes in 2010, with the largest increase in the years age group20-44 years: 465,00045-64 years: 1,052,000≥65 years: 390,000Source: National Health and Nutrition Examination Survey estimates projected to the year 2010Source: National Health and Nutrition Examination Survey estimates projected to the year 2010National Diabetes Information Clearinghouse. National Diabetes Statistics, Available at:ReferenceNational Diabetes Information Clearinghouse. National Diabetes Statistics, Available at:4
5 Insulin and oral medication 14% Treatment of DiabetesNo medication 16%Insulin only 12%Insulin and oral medication 14%Oral medication only 58%Among adults with a diagnosis of diabetes, either type 1 or type 2, 12% take insulin only; 14% take both insulin and oral medication; 58% take oral medication only; and 16% do not take either insulin or oral medicationSource: National Health Interview SurveyNational Diabetes Information Clearinghouse. National Diabetes Statistics, Available at:ReferenceNational Diabetes Information Clearinghouse. National Diabetes Statistics, Available at:5
6 Types of Diabetes Type 1 diabetes Type 2 diabetes Others Beta-cell destructionDo NOT make insulinType 2 diabetesProgressive deficit of insulin secretionDo make insulin, but resistant and decreases over timeOthersGestationalChemical or drug inducedDisease
7 Diagnosis of Diabetes A1c Fasting glucose 2-h post OGTT glucose ≥6.5% ≥126 mg/dL≥200 mg/dLPre-5.7–6.4%100–125 mg/dL140–199 mg/dLADA. 2. Classification and Diagnosis. Diabetes Care 2015;38(suppl 1):S9-10; Table 2.1and 2.3
15 Insulins (2) Short and Rapid-acting To bolus for meals or to correct high glucose
16 Insulins (3)Mixed (basal and short or rapid-acting)
17 Insulins Compared to Normal Insulin Profile glargine / determiraspart / lispro / glulisineRegularNPH100BLD80Insulin6040200600060008001800120024000600Time of dayB=breakfast; L=lunch; D=dinner17
18 Components of Insulin Pumps Infusion SetReservoir(for insulin)Very thin cannulain subcutaneous tissuePicture from diabetes.niddk.nih.gov18
19 How Does a Pump Work? Reservoir is filled with rapid acting insulin Infusion set—administers insulin SQ 24 hours/dayoften placed in the abdomen, thigh or hip/buttock areapatient can disconnect pump from the infusion set and reconnect later (exception: disposable pumps)Pump programmed to administer—Basal – continuous rate/hour to maintain glucose control when NOT eatingPrandial – bolus per patient for nutrition intakeCorrection – bolus per patient for high glucosePatient should NOT be disconnected from the pump for more than to 2 hours
21 Carbohydrate Foods Fruit and fruit juices Milk and yogurt Starch (bread, rice, potatoespasta, cereal)Fruit andfruit juicesMilk and yogurtSweetsDigestedGlucose fromCarbohydrate foodsBloodstream2004 Adapted from International Diabetes Center, Minneapolis
22 Preoperative Assessment A detailed history of diabetes therapy is essential to guide the practitioner in preoperative instructionsmedication therapycharacteristics of the surgerywhen the patient must stop eating prior to the proceduretiming of the procedureduration of the procedure
23 Clinic Assessment Type of diabetes type 1 patients CANNOT be without insulinDoes patient reliably glucose monitorA1cHow well has the patient been controlling glucose?Should elective surgery be postponed?Comorbidity riskWound healingRisk of infection
24 Estimated Average Blood Glucose (mg/dL) over 3 to 4 months A1c971261541832122402692983261067895111213A1C (Percent)Estimated Average Blood Glucose (mg/dL) over 3 to 4 monthsNormal to 6%
25 Clinic Assessment (2) Hypoglycemia Symptomatic of hypoglycemia? At what glucose level is patient symptomatic?When does hypoglycemia usually occur?Hypoglycemia is defined by theAmerican Diabetes Association as a blood glucose less than 70 mg/dL.Some patients have symptoms at higher glucose levels.
26 Obtain dose and specific timing Clinic AssessmentOral diabetes medicationInsulinHypoglycemic injectablesInhalable insulinObtain dose and specific timing
27 Pre-Surgery Medication Guidelines Oral Diabetes MedicationsGuidelinesSee List BelowHold dose(s) the day of procedure.metforminglyburide, glipizide, glimepiridesitagliptin, saxagliptin, linagliptin, alogliptin, vildagliptincanagliflozin, dapagliflozin, empagliflozinpioglitazone, rosiglitazoneacarbose, miglitolrepaglinide, nateglinidecombinations of these drugs
28 Pre-Surgery Medication Guidelines (2) InsulinGuidelinesRapid-acting or short-acting(Regular, lispro, aspart, glulisine)Hold scheduled mealtime dose the day of procedure.If using sliding (correction) scale insulin, dose according to scale to correct elevated glucoses.Long-acting(glargine, detemir)If taking ONLY glargine or detemir:Take 75% of usual dose evening before procedure.Take 75% of usual morning dose day of procedure.If taking glargine or determir with meal time insulin:Take usual dose evening before procedure.Intermediate(NPH)Take 50% of usual morning dose day of procedure.
29 Pre-Surgery Medication Guidelines (3) InsulinGuidelinesMixed Insulin:(70/30, 75/25, 50/50)Take usual dose evening before procedure.Hold dose day of procedure. Recommend contacting the patient’s provider for further orders.Insulin Concentrated:R-U-500Take 50% usual dose evening before procedure.Insulin PumpsContinue BASAL rate only. Decrease BASAL rate by 25% the day of procedure. Instruct patient to bring extra pump supplies to the procedure.Inhalable Insulin:Afreeza ®Hold scheduled mealtime dose day of procedure.
30 Pre-Surgery Medication Guidelines (4) Hypoglycemic InjectablesGuidelinesalbiglutidedulaglutideexenatide, exenatide XRliraglutidepramlintideHold dose(s) day of procedure.
31 Pre-Surgery Glucose Management OUTPATIENTSMonitor glucose morning of procedure and every hours until procedureCorrect HYPERglycemia per usual routine if using sliding (correction) scale insulinFor symptoms of HYPOglycemia or blood glucose <100 mg/dL, drink 4 oz of CLEAR fruit juice. Then monitor glucose every 15 minutes. Repeat treatment until glucose >100 mg/dL.Hospital or procedure areas will manage glucose upon arrival.
32 Pre-Surgery Glucose Management (2) INPATIENTSMonitor glucose prior to procedureCorrect HYPERglycemia per sliding (correction) scale insulin or per physician orderFollow HYPOglycemia protocol if neededPreoperative nursing will manage glucose per Anesthesia orders after arrival to surgical area
33 Hyperglycemia Pre-Surgery CausesInappropriate discontinuation of diabetes medicationHistory of poor glucose controlStress hyperglycemiaWhen to post-pone surgeryAcute complications of hyperglycemiaDehydrationKetoacidosisHyperosmolar nonketotic state
34 Hypoglycemia Pre-Surgery Hypoglycemia is defined by theAmerican Diabetes Association as a blood glucose less than 70 mg/dL.Some patients have symptoms at higher glucose levels.Follow hypoglycemia protocolD50 IVDextrose containing IV fluids
35 Intra and Post-Operative Management Glucose goalPatient outcomesInsulin therapyInsulin pumps
36 Intraoperative Glucose Goal Patients with well controlled glucosemg/dLmg/dL for coronary bypass surgeryPatient with poorly controlled glucosePreop glucose baselineSymptomatic of hypoglycemia at normal glucoseIncreased oxidative stress with glucose reduction
37 Postoperative Outcomes Retrospective study in 55,408 noncardiac surgeriesHigher rates of postoperative infection were associated with a mean 24 hour postoperative serum glucose concentrations of 150 mg/dL or higherKing, J.T., et. al. (2011). Glycemic control and infections in patients with diabetes undergoing noncardiac surgery. Annals of Surgery. 253(1),
38 Postoperative Outcomes (2) Perioperative hyperglycemia (>180 mg/dL) was associated with adverse outcomes in general surgery patients with and without diabetes (11, 633)Reoperative interventionsInfectionsDeathPatients with hyperglycemia on the day of surgery who received insulin (with or without diabetes) had no significant increase in these adverse outcomesKwon, S., et. al. (2012). Importance of perioperative glycemic control in general surgery: A report from the Surgical Care and Outcomes Assessment Program. Ann Surgery, 257(1), 8-14.
39 Glucose Control with Insulin SubcutaneousRapid or short actingShort acting preferred (aspart, lispro, glulisine)Injection before and/or after surgeryNot often during surgeryIV insulinIV pushInsulin pump (continuous subcutaneous insulin infusion-CSII)Insulin infusionMajor surgeriesReplace insulin pump
40 Insulin Pump Therapy or CSII Insulin pumps are a SAFETY concern perioperativelySeveral different models availableWith tubing, without tubing, wireless, disposableContinuous glucose sensorCannot be exposed to MRI, CT scans and X-raysBasal rate may not be accurate when patient NPOPatient not alert to self-manage!There are NO standardized guidelines!
41 CSII Perioperative Guidelines Abbott NW Hospital task team developedClinical specialist, anesthesia, managers, pharmacy, nursing, medical safety officerCSII may be considered—For surgical procedures 2 hours or less of actual scheduled OR timeIf the infusion site is not located in the operative areaIf glucose <300 mg/dLIf there will be no MRI, CT scan or X-rays
42 CSII Perioperative Guidelines (2) PreoperativeMetered glucose within 60 minutes of arrivalRN contacts Diabetes CNS or hospitalist for assessmentDecision made if CSII or alternative insulin planClose relationship with AnesthesiaDiabetes CNS or hospitalist documents recommendations
43 CSII Perioperative Guidelines (3) IntraoperativeCSII if meets criteriaBasal rate (may be reduced)CSII disconnected for short procedures with radiologyMay give bolus dose of insulin via pump before disconnectInsulin infusionProcedures >2 hoursMajor surgeryExpect high doses of pain meds post opInitiation rate determined by Diabetes CNS or hospitalistMetered glucose every 1 hour
44 CSII Perioperative Guidelines (4) PostoperativeMetered glucose upon arrival to recoveryRN contacts Diabetes CNS or hospitalistDecision made if—Safe to discharge home for ambulatory patientsSafe to continue CSIIWill continue insulin infusionInpatient policies and protocols implementedCSIIInsulin infusion
45 SummaryKnow the type of diabetes for which your patient has been diagnosedAssess glucoses regularly perioperativelyKnow what medication your patient takes for glucose managementWhat medication and dose was taken evening prior and the day of surgeryAssess if your patient has experienced hypoglycemia overnight prior and the day of surgeryIf your patient uses a CSII, collaborate with the perioperative team for safe use with surgery
47 ReferencesAbdelmalak, B., et al. (2012). Perioperative glycemic management in insulin pump patients undergoing noncardiac surgery. Current Pharmaceutical Design.18, Boyle, M. E., et.al. (2012). Guidelines for application of continuous subcutaneous insulin infusion (insulin pump) therapy in the perioperative period. Journal of Diabetes Science and Technology. 6(1), Desai, S. P., et. al. (2012). Strict versus liberal target range for perioperative glucose in patients undergoing coronary artery bypass grafting: A prospective randomized control trial. The Journal of Thoracic and Cardiovascular Surgery, 143, Joshi, G. P., et. al. (2010). Society for ambulatory anesthesia consensus statement on perioperative blood glucose management in diabetic patients undergoing ambulatory surgery. Anesthesia Analg, 111, King, J.T., et. al. (2011). Glycemic control and infections in patients with diabetes undergoing noncardiac surgery. Annals of Surgery. 253(1), Kwon, S., et. al. (2012). Importance of perioperative glycemic control in general surgery: A report from the Surgical Care and Outcomes Assessment Program. Ann Surgery, 257(1), Micromedex Solutions. (2015). Drug reference library. Retrieved February 6, 2015, from Smiley DD, Umpierrez GE. (2006). Perioperative glucose control in the diabetic or non diabetic patient. South Med J. 99:580. UpToDate. (2013). Perioperative management of diabetes mellitus. Retrieved September 20, 2013, from