1. Perioperative Management Diabetes Mellitus Adrenal Insufficiency
William Harper, MD, FRCPC
Endocrinology & Metabolism
Assistant Professor of Medicine, McMaster University

2. Perioperative DM References
An Update on Perioperative Management of Diabetes. Arch Int Med, 159: , 1999.
Inpatient Management of Adults with Diabetes. Diabetes Care. 18: , 1995.
Perioperative management of diabetes mellitus. Dec 18, 2001.

3. BS > 11.1 mmol/L Renal threshold for glycosuria (normal GFR)
Decreased WBC function
Chemotaxsis
Phagocytosis
Decreased Wound Healing

4. Goals of Perioperative DM Management
“Avoid hypoglycemia and marked hyperglycemia”
Target BS: 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

5. 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!

6. 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)

8. Preoperative Assessment
Glycemic Control adjustments
Fasting & 3AM CPG:
If running high (> 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 mM:
10-20% reduction in the intermediate or long-acting insulin taken night before surgery
Increase the duration OHA(s) are held before surgery

9. Preoperative Assessment
When to hold OHA?
Hold on AM of surgery!
When to hold for longer (24-48h)?
FBS running low
CRF: creat > uM (~ 50% decrease GFR)
OHA still appropriate?
Long-acting agents (chlorpropamide)

10. Insulin Type Starts Peaks Duration Humalog NovoRapid 5-10 min 1-2 hrs
Regular
30 min
2-4 hrs
6-8 hrs
NPH
Lente
6-10 hrs
16-24 hrs
Ultralente
4-6 hrs
8-24 hrs
24-36 hrs
Glargine
Immediately
None
Up to 24 hrs

11. Preoperative Assessment
When to hold Insulin?
Hold their insulin dose on AM of surgery!
The last dose of insulin day before surgery:
acB acL acD qhs
Bedtime NPH (+/-bids) N
NPH bid N N
30/70 bid / /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.

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

13. Glycemic control during Surgery
Dependent on:
Prior DM Rx regimen
Surgery: Duration & Complexity
T2DM on Diet Rx +/- OHA
T1/T2DM on Insulin - Minor surgery
(< 2h, able to eat lunch)
3) T1/T2DM on Insulin - Major surgery

14. Perioperative Rx Options
Hold OHA
½ AM insulin as NPH SC
IV insulin gtt
IV D5W cc/h

15. 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 0.9 U/h (9cc/h) or start at a rate dependent on patient’s insulin dose:
IV insulin gtt rate = ( ½ TDD ) / 24

16. 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:
< Call MD
U/h ( 7cc/h)
U/h ( 9cc/h)
U/h (12cc/h)
U/h (15cc/h)
U/h (20cc/h)
U/h (25cc/h)
U/h (30cc/h)
U/h (35cc/h)
U/h (40cc/h)
> Call MD

17. T2DM on Diet Rx +/- OHA Patient holds OHAs on AM of surgery CBG @ 7AM:
< 3.0 Consider postpone OR
IV D5W cc/h
Proceed with OR, no Rx necessary
> 11.1 IV insulin gtt
IV D5W cc/h
> 20.0 Check urine ketones, consider postpone OR

18. Postop: T2DM on Diet Rx +/- OHA
Postop: CBG in recovery then bid
If not eating postop & BS > 11.1 mM:
IV D5W 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

19. 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
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

20. T1/T2DM on Insulin, Minor Surgery
Patient holds all AM Insulin on day of Surgery
7AM:
< 3.0 Consider postpone OR
Give ½ of total AM insulin dose as NPH SC
IV D5W cc/h
> 11.1 IV insulin gtt
> 20.0 Check urine ketones, consider postpone OR

21. 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.

22. SC Insulin Supplemental Scale
CBG
Action
< 4.0
Call MD
nil
Humalog 7U SC (0.1U/kg)
Humalog 10U SC (0.15 U/kg)
> 20.0

23. T1DM/T2DM on Insulin: Major Surgery
Patient holds all AM Insulin on day of Surgery
7AM:
< 3.0 Consider postpone OR
IV insulin gtt
IV D5W cc/h
> 20.0 Check urine ketones, consider postpone OR

24. 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

25. acB acL acD qhs Rx 22 (5R) 9 3.1 (O.J.) 15 acB N20 R10 acD N10 R5 20 78 17
(RN calls)
Surgeon: ?
Internal Medicine: ?
Endocrinologist: ?

26. acB acL acD qhs Rx 22 (5R) 9 3.1 (O.J.) 15 acB N20 R10 acD N10 R5 20 78 17
(RN calls)
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 tonight
Decrease acB N15 R7 starting tomorrow AM
Check 3AM BS tonight

27. (Goal: BS 7.0-11.1 mM) Summary: Periop DM Management DM Patient
On Insulin
Preop BS > 11.1 mM
Diet/OHA
Minor Surgery
Major Surgery
½ AM insulin
as NPH S.C.
Hold OHA
IV insulin gtt
D5W IV gtt
(Goal: BS mM)

28. Evidence to support perioperative BS control?
DIGAMI
AMI, prior dx DM or BS > 11 mM
IV insulin gtt 5 U/h
Titrated to keep BS mM
Insulin IV > 24h  MDI > 3 months
No in-hospital mortality benefit.
Rx Increased hospitalization by 1.8d
0.5% reduction 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

29. 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 2-4 U/h, titrated to BS 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?

30. Benefit of Perioperative Insulin
DIGAMI
Reduce perioperative cardiac event risk?
Leuven Study
Reduce sepsis
Reduce ICU associated morbidity & mortality

31. 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

32. 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