1. 21 st October 2011 Perioperative Care of the Person with Diabetes Alison Gebuehr CNC Diabetes JHH Credentialled Diabetes Educator Adapted from presentation by Hilary Fejsa

2. Things to Consider Why do we need to bother Risks of Surgery Pre Operative Considerations Planning Care –Type 1 –Type 2 –Other factors –Pumps Post Operative Care

3. Perioperative Care of the Person with Diabetes Rationale –25% of pts with diabetes will require surgery –Periop mortality rates up to 5x greater than nondiabetics –Random BGL > 11.1mmol- general med / surg pts 18 fold increase in in-hospital deaths, longer length of stay & greater risk of infection –DM accounts for nearly ¼ of all perioperative deaths –Infections account for 55% of postop complications –DM is independent predictor of postop MI

4. Goals of Surgical Management Maintain glycaemic control Prevent hypoglycaemia Prevent marked hyperglycaemia Prevent ketoacidosis Prevent electrolyte and fluid imbalance Prevent postoperative complications

5. Factors Affecting Diabetes Control with Surgery Stress and anxiety Fasting state Anaesthesia Current diabetes control Chronic diabetes complications Other medications

6. Risks of Surgery for Diabetic Patients Hyperglycaemia –Stress, fear, pain, anxiety, causative illness, infection, drugs Hypoglycaemia –Fasting, postop nausea, vomiting Potential for DKA, hyperosmolar coma, lactic acidosis Increased risk of postoperative complications –Poor healing, infections, increased risk of thrombosis Exacerbation of pre existing comorbidities –Cardiovascular

7. The Perfect Patient Planned procedure vs emergency Good control (HbA1C <7%) Insulin or medication regime stable Educated about risks and expectations Reviewed medically (either by GP or Specialist) prior to procedure Stable Comorbidities

8. Pre-op Planning Where possible, pt should have a pre- procedural assessment to assess diabetes management, complications, co-morbidities, and to prepare a management plan

9. Pre-op Planning Questions to ask ? – What type of diabetes do they have - type 1 or type 2 How do they treat their diabetes- insulin, oral hypoglycaemic agents or lifestyle What type of procedure- major, minor, gut surgery, anticipated recovery time, anticipated post operative complications for individual patients, emergency or planned surgery. When is the procedure- morning or afternoon

10. Pre-op Planning Pre-op control - good or poor control, stability of existing comorbidities, nutritional status What things will influence post-op recovery Nutrition Wounds Recovery time Drugs needed (e.g steroids) Infection Do they need to improve control prior to surgery

11. Lets look at our different groups of patients!

12. Planning Care – Lifestyle Or Oral Agents Fast as advised by pre-operative clinic or anaesthetist. Stop oral agents as advised. Biguanides (eg Metformin) should be ceased at least 24 hours prior to surgery to decrease risk of lactic acidosis. Be aware of combination drugs containing Metformin. Other oral agents- omit day of surgery Unplanned surgery – check renal function, hydrate well if on Metformin. Take other medications (blood pressure drugs etc) on day of surgery.

13. Planning Care – Lifestyle Or Oral Agents Test blood glucose levels prior to surgery and as required during surgery More frequently if poor control prior to surgery, major surgery, unplanned surgery. Pre-op – If BGL < 5mmol- may need IV Dextrose or clear juice (no pulp) if greater than 2 hrs till surgery time If BGL > 10mmol- consider commencing insulin infusion Consider insulin/dextrose infusion if BGL’s unstable or major surgery. Review by team as needed

14. Planning Care - Insulin Treated Type 1 or Type 2 Can be on a combination of insulin and oral therapy (eg Metformin) May need insulin/dextrose infusion – dependent on type of surgery Pre and post op planning based on current insulin regime

15. Basal Insulin Need 50 –70 % of total insulin for BASAL needs Normal daily activity – keep body running Prevents ketosis and loss of diabetic control

16. Planning care - Insulin Treated Fast as advised by pre-operative clinic or anaesthetist Take other medications (blood pressure drugs etc) on day of surgery. Insulin as per next slide Test blood glucose levels prior to surgery and as required during surgery More frequently if poor control prior to surgery, major surgery, unplanned surgery. Pre-op – If BGL < 5mmol- may need IV Dextrose or clear juice (no pulp) if greater than 2 hrs till surgery time If BGL > 10mmol- consider commencing insulin infusion Consider insulin/dextrose infusion if BGL’s unstable or major surgery. Review by team as needed

17. Insulin Regimes Long acting once day –if nocte, usual dose evening before –If mane, half of normal dose at usual time Pre-mixed Insulins (mane or BD) –Give half of normal morning dose of insulin at usual time Basal Bolus with evening long acting insulin (PM dose of long acting insulin and short acting doses with meals) – Give normal dose long acting in the evening before surgery – Withhold short acting doses while fasting on day of surgery Basal Bolus with mane long acting insulin (AM dose of long acting insulin and short acting doses with meals) –Give half of morning dose of long acting insulin on morning of surgery –Withhold short acting doses while fasting on day of surgery Other Regimens (including insulin pump therapy) seek specialist advice

18. Insulin dextrose infusion should be commenced when fasting Use 5% Glucose at 125mls/h – provides basal energy, prevents ketosis, prevents hypo’s. Titrate insulin to blood glucose levels using appropriate algorithm – algorithm used is based on patients usual insulin dose Hourly BGL’s Start back on normal insulin regime when able to eat normally and blood glucose control is acceptable. Planning Care - Insulin Treated (major procedure)

19. Insulin infusion algorithms

20. Insulin Pumps Patient is the expert Not to be disconnected unless patient is receiving insulin Should be removed during CT scans etc Should be protected from accidental disconnection

21. Insulin Pumps Minor Procedure –Patient should be able to manage pump –Leave on at basal rate –Resume bolus when eating Major Procedure –Disconnect pump treat as for major procedure on basal bolus insulin

22. Post Operative Care (All Patients) Resume normal meals, insulin/medications as soon as possible May need close monitoring for post operative complications – infection, poor healing, thrombosis, worsening of comorbidities May need adjustments to normal treatment (short or long term) depending on prior control, new medications, post operative problems

23. Post Operative Care (All Patients) REMEMBER!!! Very important to maintain tight control in immediate post-op period Aim BGL 5-10mmol to reduce post-op complications Aid wound healing Reduce risk of infection First 24- 72 hours crucial

24. Assessing the patient Have they had education and when? How do they manage at home? Is their current problem going to impact on their management? Has their management changed due to their condition? Do they need dietary advice? Do they need specialist input? Do they need ongoing education? Will they be able to cope at home? Are other services needed?

25. NEVER LET A CHANCE GO BY ALWAYS Assess knowledge of diabetes self management and need for further education. Organise appropriate follow up if needed with diabetes educator, endocrinologist, podiatrist etc

26. Bibliography Moghissi, ES, Korytkowski, MT, DiNardo, M, et al. AACE and ADA consensus statement on inpatient glycemic control. Diabetes Care 2009. 32:1119 Smiley, DD, Umpierrez, GE Perioperative glucose control in the diabetic or nondiabetic patient. South Med J 2006; 99:580 Mantz, J., Dahmani, S, Paugam-Burtz, C. 2010. Outcomes in perioperative care. Curr Opin Anaesthesiol; 23:201-208 Lipshutz, A, Gropper, M. 2009. Anaesthesiology: 110:408-21 Ramos, M, Khalpey, Z, Lipsitz, S., Steinberg, J., et al. 2008. Relationship of Perioperative hyperglycemia and postoperative infection in patients who undergo general and vascular surgery. Annals of Surgery. Vol 248: 4. 585-591 Noordzij PG, Boersma E, Schreiner, F, et al. @007. Increased preoperative glucose levels are associated with perioperative mortality in patients undergoing noncardiac, nonvascular surgery. Eur J Endocrinol.2156:137-142. Akinbami, F, Askari, R., Steinberg, J., Panizales, M., Rogers WO Jr..2011. Factors affecting morbidity in emergency general surgery. Apr. 201 Edelson GW, Fachnie JD, Whitehouse FW. Perioperative management of diabetes. Henry Ford Hosp Med J 1990;38: 262-265