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

Perioperative DM References An Update on Perioperative Management of Diabetes. Arch Int Med, 159:2405-2411, 1999. Inpatient Management of Adults with Diabetes. Diabetes Care. 18:870-878, 1995. Perioperative management of diabetes mellitus. www.uptodate.com, Dec 18, 2001.

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

Goals of Perioperative DM Management “Avoid hypoglycemia and marked hyperglycemia” Target BS: 7.0 - 11.0 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

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!

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)

Preoperative Assessment Glycemic Control adjustments Fasting & 3AM CPG: If running high (> 11-15 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 7-11.0 mM: 10-20% reduction in the intermediate or long-acting insulin taken night before surgery Increase the duration OHA(s) are held before surgery

Preoperative Assessment When to hold OHA? Hold on AM of surgery! When to hold for longer (24-48h)? FBS running low CRF: creat > 120-150uM (~ 50% decrease GFR) OHA still appropriate? Long-acting agents (chlorpropamide)

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

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 30/70 30/70 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.

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

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

Perioperative Rx Options Hold OHA ½ AM insulin as NPH SC IV insulin gtt IV D5W 75-100 cc/h

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

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: <4.0 Call MD 4.1-5.0 0.7 U/h ( 7cc/h) 5.1-6.0 0.9 U/h ( 9cc/h) 6.1-7.0 1.2 U/h (12cc/h) 7.1-9.0 1.5 U/h (15cc/h) 9.1-11.0 2.0 U/h (20cc/h) 11.1-13.0 2.5 U/h (25cc/h) 13.1-15.0 3.0 U/h (30cc/h) 15.1-17.0 3.5 U/h (35cc/h) 17.1-20.0 4.0 U/h (40cc/h) >20.1 Call MD

T2DM on Diet Rx +/- OHA Patient holds OHAs on AM of surgery CBG @ 7AM: < 3.0 Consider postpone OR 3.1-4.0 IV D5W gtt @ 75-100 cc/h 4.1-11.0 Proceed with OR, no Rx necessary > 11.1 IV insulin gtt IV D5W gtt @ 75-100 cc/h > 20.0 Check urine ketones, consider postpone OR

Postop: T2DM on Diet Rx +/- OHA Postop: CBG in recovery then bid If not eating postop & BS > 11.1 mM: IV D5W 75-100 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

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 967-1111 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

T1/T2DM on Insulin, Minor Surgery Patient holds all AM Insulin on day of Surgery CBG @ 7AM: < 3.0 Consider postpone OR 3.1-11.0 Give ½ of total AM insulin dose as NPH SC IV D5W gtt @ 75-100 cc/h > 11.1 IV insulin gtt > 20.0 Check urine ketones, consider postpone OR

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.

SC Insulin Supplemental Scale CBG Action < 4.0 Call MD 4.1-11.0 nil 11.1-15.0 Humalog 7U SC (0.1U/kg) 15.1-19.9 Humalog 10U SC (0.15 U/kg) > 20.0

T1DM/T2DM on Insulin: Major Surgery Patient holds all AM Insulin on day of Surgery CBG @ 7AM: < 3.0 Consider postpone OR 3.1-19.9 IV insulin gtt IV D5W gtt @ 75-100 cc/h > 20.0 Check urine ketones, consider postpone OR

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

acB acL acD qhs Rx 22 (5R) 9 3.1 (O.J.) 15 acB N20 R10 acD N10 R5 20 7 8 17 (RN calls) Surgeon: ? Internal Medicine: ? Endocrinologist: ?

acB acL acD qhs Rx 22 (5R) 9 3.1 (O.J.) 15 acB N20 R10 acD N10 R5 20 7 8 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

(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 7.0-11.1 mM)

Evidence to support perioperative BS control? DIGAMI AMI, prior dx DM or BS > 11 mM IV insulin gtt started @ 5 U/h Titrated to keep BS 7-10.9 mM Insulin IV > 24h  MDI > 3 months No in-hospital mortality benefit. Rx Increased hospitalization by 1.8d 0.5% reduction HbA1c @ 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

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 insulin @ 2-4 U/h, titrated to BS 4.4-6.1 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?

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

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

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