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 million
Source: Centers for Disease Control and Prevention, National Center for Health Statistics, Division of Health Interview Statistics, data from the National Health Interview Survey
Reference
Centers 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 group
20-44 years: 465,000
45-64 years: 1,052,000
≥65 years: 390,000
Source: National Health and Nutrition Examination Survey estimates projected to the year 2010
Source: National Health and Nutrition Examination Survey estimates projected to the year 2010
National Diabetes Information Clearinghouse. National Diabetes Statistics, Available at:
Reference
National Diabetes Information Clearinghouse. National Diabetes Statistics, Available at: 4

5. Insulin and oral medication 14%
Treatment of Diabetes
No 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 medication
Source: National Health Interview Survey
National Diabetes Information Clearinghouse. National Diabetes Statistics, Available at:
Reference
National Diabetes Information Clearinghouse. National Diabetes Statistics, Available at: 5

6. Types of Diabetes Type 1 diabetes Type 2 diabetes Others
Beta-cell destruction
Do NOT make insulin
Type 2 diabetes
Progressive deficit of insulin secretion
Do make insulin, but resistant and decreases over time
Others
Gestational
Chemical or drug induced
Disease

7. Diagnosis of Diabetes A1c Fasting glucose 2-h post OGTT glucose ≥6.5%
≥126 mg/dL
≥200 mg/dL
Pre-
5.7–6.4%
100–125 mg/dL
140–199 mg/dL
ADA. 2. Classification and Diagnosis. Diabetes Care 2015;38(suppl 1):S9-10; Table 2.1and 2.3

8. Medications for Diabetes
Oral agent
9 categories
5 categories mostly used
Non-insulin injectable
2 categories
Insulin
5 categories

9. Oral Medications Biguanides Sulfonylureas i hepatic glucose production
metformin
Liver
Sulfonylureas
h insulin secretion
glyburide
glipizide
glimepiride
Pancreas

10. Oral Medications (2) TZDs DPP-4 Inhibitors h insulin sensitivity
pioglitazone
rosiglitazone
Muscle
DPP-4 Inhibitors
h insulin secretion (with food)
i glucagon secretion
sitagliptin
saxagliptin
linagliptin
alogliptin
Pancreas and Liver

11. Oral Medications (3) SGLT2 Inhibitors canagliflozin deapagliflozin
Blocks glucose reabsorption by the kidney h glucosuria
canagliflozin
deapagliflozin
empagliflozin
Kidney

12. Non-insulin Injectables
GLP-1 Receptor Agonists
h insulin secretion (with food)
i glucagon secretion
Slows gastric emptying
h satiety
exenatide
exenatide extended release
liraglutide
albiglutide
dulaglutide

13. Non-insulin Injectables (2)
Amylin Mimetics
i glucagon secretion
Slows gastric emptying
h satiety
pramlintide

14. Insulins
Basal
Controls glucose when NOT eating

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 / determir
aspart / lispro / glulisine
Regular
NPH
100 B L D 80
Insulin 60 40 20
0600
0600
0800
1800
1200
2400
0600
Time of day
B=breakfast; L=lunch; D=dinner 17

18. Components of Insulin Pumps
Infusion Set
Reservoir
(for insulin)
Very thin cannula
in subcutaneous tissue
Picture from diabetes.niddk.nih.gov 18

19. How Does a Pump Work? Reservoir is filled with rapid acting insulin
Infusion set—
administers insulin SQ 24 hours/day
often placed in the abdomen, thigh or hip/buttock area
patient 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 eating
Prandial – bolus per patient for nutrition intake
Correction – bolus per patient for high glucose
Patient should NOT be disconnected from the pump for more than to 2 hours

20. Meal Planning with Diabetes

21. Carbohydrate Foods Fruit and fruit juices Milk and yogurt Starch
(bread, rice, potatoes
pasta, cereal)
Fruit and
fruit juices
Milk and yogurt
Sweets
Digested
Glucose from
Carbohydrate foods
Bloodstream
2004 Adapted from International Diabetes Center, Minneapolis

22. Preoperative Assessment
A detailed history of diabetes therapy is essential to guide the practitioner in preoperative instructions
medication therapy
characteristics of the surgery
when the patient must stop eating prior to the procedure
timing of the procedure
duration of the procedure

23. Clinic Assessment Type of diabetes
type 1 patients CANNOT be without insulin
Does patient reliably glucose monitor
A1c
How well has the patient been controlling glucose?
Should elective surgery be postponed?
Comorbidity risk
Wound healing
Risk of infection

24. Estimated Average Blood Glucose (mg/dL) over 3 to 4 months
A1c 97
126
154
183
212
240
269
298
326 10 6 7 8 9 5 11 12 13
A1C (Percent)
Estimated Average Blood Glucose (mg/dL) over 3 to 4 months
Normal 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 the
American 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 Assessment
Oral diabetes medication
Insulin
Hypoglycemic injectables
Inhalable insulin
Obtain dose and specific timing

27. Pre-Surgery Medication Guidelines
Oral Diabetes Medications
Guidelines
See List Below
Hold dose(s) the day of procedure.
metformin
glyburide, glipizide, glimepiride
sitagliptin, saxagliptin, linagliptin, alogliptin, vildagliptin
canagliflozin, dapagliflozin, empagliflozin
pioglitazone, rosiglitazone
acarbose, miglitol
repaglinide, nateglinide
combinations of these drugs

28. Pre-Surgery Medication Guidelines (2)
Insulin
Guidelines
Rapid-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)
Insulin
Guidelines
Mixed 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-500
Take 50% usual dose evening before procedure.
Insulin Pumps
Continue 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 Injectables
Guidelines
albiglutide
dulaglutide
exenatide, exenatide XR
liraglutide
pramlintide
Hold dose(s) day of procedure.

31. Pre-Surgery Glucose Management
OUTPATIENTS
Monitor glucose morning of procedure and every hours until procedure
Correct HYPERglycemia per usual routine if using sliding (correction) scale insulin
For 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)
INPATIENTS
Monitor glucose prior to procedure
Correct HYPERglycemia per sliding (correction) scale insulin or per physician order
Follow HYPOglycemia protocol if needed
Preoperative nursing will manage glucose per Anesthesia orders after arrival to surgical area

33. Hyperglycemia Pre-Surgery
Causes
Inappropriate discontinuation of diabetes medication
History of poor glucose control
Stress hyperglycemia
When to post-pone surgery
Acute complications of hyperglycemia
Dehydration
Ketoacidosis
Hyperosmolar nonketotic state

34. Hypoglycemia Pre-Surgery
Hypoglycemia is defined by the
American Diabetes Association as a blood glucose less than 70 mg/dL.
Some patients have symptoms at higher glucose levels.
Follow hypoglycemia protocol
D50 IV
Dextrose containing IV fluids

35. Intra and Post-Operative Management
Glucose goal
Patient outcomes
Insulin therapy
Insulin pumps

36. Intraoperative Glucose Goal
Patients with well controlled glucose
mg/dL
mg/dL for coronary bypass surgery
Patient with poorly controlled glucose
Preop glucose baseline
Symptomatic of hypoglycemia at normal glucose
Increased oxidative stress with glucose reduction

37. Postoperative Outcomes
Retrospective study in 55,408 noncardiac surgeries
Higher rates of postoperative infection were associated with a mean 24 hour postoperative serum glucose concentrations of 150 mg/dL or higher
King, 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 interventions
Infections
Death
Patients with hyperglycemia on the day of surgery who received insulin (with or without diabetes) had no significant increase in these adverse outcomes
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), 8-14.

39. Glucose Control with Insulin
Subcutaneous
Rapid or short acting
Short acting preferred (aspart, lispro, glulisine)
Injection before and/or after surgery
Not often during surgery
IV insulin
IV push
Insulin pump (continuous subcutaneous insulin infusion-CSII)
Insulin infusion
Major surgeries
Replace insulin pump

40. Insulin Pump Therapy or CSII
Insulin pumps are a SAFETY concern perioperatively
Several different models available
With tubing, without tubing, wireless, disposable
Continuous glucose sensor
Cannot be exposed to MRI, CT scans and X-rays
Basal rate may not be accurate when patient NPO
Patient not alert to self-manage!
There are NO standardized guidelines!

41. CSII Perioperative Guidelines
Abbott NW Hospital task team developed
Clinical specialist, anesthesia, managers, pharmacy, nursing, medical safety officer
CSII may be considered—
For surgical procedures 2 hours or less of actual scheduled OR time
If the infusion site is not located in the operative area
If glucose <300 mg/dL
If there will be no MRI, CT scan or X-rays

42. CSII Perioperative Guidelines (2)
Preoperative
Metered glucose within 60 minutes of arrival
RN contacts Diabetes CNS or hospitalist for assessment
Decision made if CSII or alternative insulin plan
Close relationship with Anesthesia
Diabetes CNS or hospitalist documents recommendations

43. CSII Perioperative Guidelines (3)
Intraoperative
CSII if meets criteria
Basal rate (may be reduced)
CSII disconnected for short procedures with radiology
May give bolus dose of insulin via pump before disconnect
Insulin infusion
Procedures >2 hours
Major surgery
Expect high doses of pain meds post op
Initiation rate determined by Diabetes CNS or hospitalist
Metered glucose every 1 hour

44. CSII Perioperative Guidelines (4)
Postoperative
Metered glucose upon arrival to recovery
RN contacts Diabetes CNS or hospitalist
Decision made if—
Safe to discharge home for ambulatory patients
Safe to continue CSII
Will continue insulin infusion
Inpatient policies and protocols implemented
CSII
Insulin infusion

45. Summary
Know the type of diabetes for which your patient has been diagnosed
Assess glucoses regularly perioperatively
Know what medication your patient takes for glucose management
What medication and dose was taken evening prior and the day of surgery
Assess if your patient has experienced hypoglycemia overnight prior and the day of surgery
If your patient uses a CSII, collaborate with the perioperative team for safe use with surgery

46. Questions

47. References
Abdelmalak, 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