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Peri-operative Management of Diabetes Mellitus

Peri-operative Management of Diabetes Mellitus. Christian Sinclair AIM Presentation December 18, 2002. Overview. Pre-operative Evaluation Hospital Barriers to Glucose Control Common Errors in Glucose Management Glycemic Control Intervention Trials Hospital Utilization Recommendations

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Peri-operative Management of Diabetes Mellitus

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  1. Peri-operative Management of Diabetes Mellitus Christian Sinclair AIM Presentation December 18, 2002

  2. Overview • Pre-operative Evaluation • Hospital Barriers to Glucose Control • Common Errors in Glucose Management • Glycemic Control • Intervention Trials • Hospital Utilization • Recommendations • References

  3. Preoperative Evaluation • DM is a major risk factor • Silent ischemia, CAD • Evaluate for end organ dysfunction • Nephropathy, Autonomic Neuropathy • CAD, PVD • Baseline Glycemic Control • Current Therapies Utilized • Type of Surgery • Type of Anesthesia

  4. Hospital Barriers • Diabetes becomes secondary • Infection • Fever • Glucocorticoids • Surgery/Trauma • Medical Stress • Decreased physical activity • Change in diet and drugs • Patient has loss of control

  5. Common Errors • Admission Orders • Overly High Glycemic Targets • Lack of Therapeutic Adjustment • Overutilization of Sliding Scales • Underutilization of Insulin Infusions

  6. Benefits of Glycemic Control Improved leukocyte function Improved immunoglobulin complement fixation Improved nutrient delivery Reduced infection risk Improved response of endothelium-dependent vasodilation Increased blood flow to wounds Normalization of coagulation Less intravascular volume changes Normalize GFR Improved wound healing Improved oxygen delivery Less electrolyte shifts Normal skin fibroblast proliferation Less thrombotic complications Elevated free fatty acids and cardiotoxicity Increased growth factor production

  7. Interventional Trials • DIGAMI • Diabetes Insulin-Glucose Infusion in Acute MI • 620 pts. with MI • Randomized to: • Standard diabetic care • Standard diabetic care and insulin-glucose IV for >24 hrs. (Goal 126-196 mg/dl) • ALSO rec’d 3 mos. of multi-dose insulin

  8. DIGAMI – up to discharge • Mean FSBG at 24 hours • Control • 211 • Standard plus insulin-glucose infusion • 173 • Mean FSBG at discharge • Control • 162 • Standard plus insulin-glucose infusion • 148

  9. DIGAMI – 3.4 years of follow-up • Deaths • Control • 138 • Standard plus insulin-glucose infusion • 102 (ARR 28%, P=0.01) NNT 100/28 = 3.6

  10. N Engl J Med 11/8/01 • Van den Berghr et al. • Belgium • RCT of ventilated, ICU pts • Randomized to: • Intensive insulin therapy (80-110 mg/dl) • Conventional insulin (180-200 mg/dl)

  11. N Engl J Med 11/8/01 • Reason for admission • 63% - Cardiac surgery (mostly CABG) • 37% - Other surgery • Prior diabetes • Only 13% of patients (5% rec’d insulin)

  12. N Engl J Med 11/8/01 • Intensive Therapeutic Group • Insulin infusion started if FSBG was greater than 110 • Goal of 80-110 in the ICU • Checked Q4 • Goal of 180-200 after transfer out of unit

  13. N Engl J Med 11/8/01 • Conventional Therapeutic Group • Insulin infusion started if FSBG was greater than 215 • Goal of 180-200 in the ICU • Checked Q4 • Goal of 180-200 after transfer out of unit • In both groups, IV glucose was started and advanced to parenteral or enteral feeding ASAP

  14. N Engl J Med 11/8/01 • Study was designed to study 2500 patients to detect a mortality difference • STOPPED EARLY!!

  15. N Engl J Med 11/8/01 Conventional Intensive P value Mortality Death during intensive care 8.0% 4.6% <0.04 Death among ICU > 5 days 20.2% 10.6% <0.005 In-hospital death All patients 10.9% 7.2% 0.01 ICU > 5 days 26.3% 16.8% 0.01

  16. N Engl J Med 11/8/01 Conventional Intensive P value Morbidity Pts requiring >14 d ICU 15.7% 11.4% 0.01 Pts requiring >14 d Vent 11.9% 7.5% 0.003 Peak Creat > 22.5 12.3% 9.0% 0.04 Peak PUN > 54 11.2% 7.7% 0.02 HD or CVVHD 8.2% 4.8% 0.007 Peak Bilirubin > 2 26.7% 22.4% 0.04 Septicemia 7.8% 4.2% 0.003 EMG + ICU polyneuropathy 51.9% 28.7% <0.001

  17. Recommendations • Individualize Therapy • Development of hospital specific algorithims or protocols? • Multi-disciplinary (MD, RN, dietician) • Pain is the fifth vital sign…..should blood glucose be the 6th

  18. Recommendations • Diet • ADA 1800, 2000 kcal • Chance for education….. • Other comorbidities • Obesity, hyperlipidemia, hypertension

  19. Recommendations • Glucose Monitoring • QAC & QHS initially • May decrease to BID if stable • Chance for education…..

  20. Recommendations • Glucose Control • Goal of 120-200 • Pre-op • Early peri-op • Late post-op • Sliding scale • Special considerations

  21. Preoperative phase • Schedule surgery as early as possible to avoid interfering with regimen • Education about hypo/hyperglycemic episodes (warning signs) • Monitored every 1-2 hours before during and after surgery

  22. Preoperative phase • Type 2 DM (diet controlled) • No therapy needed perioperatively, may use regular/lispro SQ sliding scale PRN for FSBG >200 • Type 2 DM (diet and oral tx) • Hold DM meds after MN (including metformin) • May use regular/lispro SSI PRN > 200

  23. Preoperative phase • Type 1/2 DM (with insulin) • May continue SQ insulin for short simple procedures • Switch from long acting (ultralente or lantus) to intermediate acting (NPH) 1-2 days prior to surgery (reduce hypogly) • Reduce intermediate nighttime dose

  24. Preoperative phase • Type 1/2 DM (with insulin) • Short, early procedures • Delay AM insulin until after surgery and before eating • Missed breakfast • ½ -2/3 of AM NPH dose • Missed breakfast and lunch • 1/3 - ½ of AM NPH dose, 1/3 of regular • Pumps – continue basal rate

  25. Preoperative phase • Type 1/2 DM (with insulin) • Late procedures • 1/3-½ of usual intermediate insulin and D5W 100 cc/hr • Pumps – continue basal rate • Short acting sliding scale • Long procedures (CABG, Xplant, etc.) • Insulin infusion with glucose

  26. Late postoperative phase • Hold metformin (CRI, hepatic insuff, CHF) • Sulfonylureas stimulate insulin secretion and cause hypoglycemia • Make sure eating has been established • Subcutaneous insulin should be continued with D5 supplement

  27. Special Considerations • Glucocorticoid Therapy • Mech of Hyperglycemia is multifactorial • Incr. hepatic gluconeogenesis • Inhibit glucose uptake in adipose • Alteration of receptor and post-receptor fxn • Leads to ketoacidosis • High postprandial hyperglycemia • Minimal elevation of fasting glucose • May need to add or increase insulin

  28. References • Jacober, SJ, Sowers, JR. An update on perioperative management of diabetes. Arch Intern Med 1999; 159:2405. • Malmberg K. Prospective randomized study of intensive insulin treatment on long term survival after acute myocardial infarction in patients with diabetes mellitus. BMJ. 1997;314:1512-1515. • Metchick L. Inpatient Management of Diabetes Mellitus. Am J Med 2002; 113:317-323.

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