1 / 47

Josephine Carlos-Raboca MD FPCP Gabriel V. Jasul MD FPCP FPSEM Rosa Allyn G. Sy MD FPCP FPSEM

INSULIN THERAPY AND NUTRITIONAL MANAGEMENT IN PATIENTS WITH DIABETES MELLITUS IN THE PERIOPERATIVE PERIOD. Josephine Carlos-Raboca MD FPCP Gabriel V. Jasul MD FPCP FPSEM Rosa Allyn G. Sy MD FPCP FPSEM Leilani B. Mercado-Asis, M.D., Ph.D.FPCP FPSEM FPSEM.

charo
Download Presentation

Josephine Carlos-Raboca MD FPCP Gabriel V. Jasul MD FPCP FPSEM Rosa Allyn G. Sy MD FPCP FPSEM

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. INSULIN THERAPY AND NUTRITIONAL MANAGEMENT IN PATIENTS WITH DIABETES MELLITUS IN THE PERIOPERATIVE PERIOD Josephine Carlos-Raboca MD FPCP Gabriel V. Jasul MD FPCP FPSEM Rosa Allyn G. Sy MD FPCP FPSEM Leilani B. Mercado-Asis, M.D., Ph.D.FPCP FPSEMFPSEM

  2. Insulin Therapy and Hyperglycemia in Hospitalized Patients Dr. Josephine Carlos-Raboca Dr. Leilani B. Mercado-Asis

  3. GENERAL OBJECTIVES: • To review general guidelines and treatment approaches in diabetes management in surgical patients, including in-hospital glycemic targets and intravenous and subcutaneous insulin regimens. • To review treatment guidelines on nutritional management of diabetic patients in the perioperative period, in particular, routes of feeding and insulin therapy adjustments in relation to nutritional provision. • To apply these guidelines through case-based discussion and to formulate practical treatment plans in the management of diabetic patients undergoing surgery.

  4. Case • VS, 62M • Type 2 DM X3 yrs • Rx: Glibenclamide 5 mg OD Metformin 500 mg BID • admitted due to abdominal pain

  5. CASE History 2 days PTA crampy LLQ pain increasing in severity anorexia and vomiting (-)fever (-)diarrhea,constipation ADMISSION

  6. CASE Physical Examination • Conscious, coherent • BP: 130/70; CR: 89: RR: 23/min; T: 36.8C • Wt: 80kg, Ht: 178cm BMI: 25 • Neck: (+)curvilinear scar, no palpable thyroid • Heart and lungs were unremarkable • Abdomen: flabby, normoactive bowel sounds, no organomegaly, (+) direct tenderness on the left lower quadrant area. • Extremities: (-)edema nor cyanosis

  7. CASE Course at the ER • Stat CBG 357mg/dl • Serum ketones Negative • ABG Compensated metabolic acidosis • Repeat CBG 260mg/dl IVF: Plain NSS at 30gtts/min Regular Insulin 10u/SC

  8. CASE 1st Hospital Day • Scout film of the abdomen • localized ileus • rule out a localized fluid collection or an inflammatory process. • CBC • leukocytosis with predominance of segmenters (WBC: 20.90, seg: 0.96). • Urinalysis • (+1) albumin. • Ultrasound of the abdomen • hyperechoic lesion (2.0X1.8X2.2cm) right lobe of the liver • HbA1c: 7%; FBS: 345 mg/dl • Creatinine: 0.98; Na:131mg/dl; K:3.2; SGPT: 28.1.

  9. CASE Initial Orders • Keep on NPO • Serial abdomen exam • IVF: D5 NM1L + 20meqs KCl X 30gtts/min • Refer to Endocrine service

  10. CASE 1st Hospital Day • Persistent abdominal pain • (+) Rebound tenderness, LLQ area • Surgery consult: • For exploratory Laparotomy • Endocrine clearance

  11. CASE Endocrine Consult • D5NSS X 100cc/hr • Stat CBG: 245mg/dl • 6units Regular Insulin/SC stat • CBG monitoring q4h • Standing insulin: Glargine Insulin10u SC OD • Supplemental scale: CBG Regular Insulin/SC 180 – 250 4u 251 – 350 6u >350 8u

  12. CASE CBG MONITORING SHEET Admission To OR

  13. REVIEW GENERAL PRINCIPLES OF PERIOPERATIVE MANAGEMENT OF DIABETES MELLITUS, INCLUDING NUTRITION SUPPORT, CHOICE OF TYPE AND ROUTE OF INSULIN ADMINISTRATION, FREQUENCY OF MONITORING AND FLUID MANAGEMENT

  14. Objective # 3 REVIEW GENERAL PRINCIPLES OF PERIOPERATIVE MANAGEMENT OF DIABETES MELLITUS, INCLUDING CHOICE OF, TYPE AND ROUTE OF INSULIN ADMINISTRATION, FREQUENCY OF MONITORING AND FLUID MANAGEMENT

  15. GENERAL PRINCIPLES OF PERIOPERATIVE MANAGEMENT OF DIABETES MELLITUS • Oral agents may be contraindicated • Dose adjustment of oral agents may require time and may be ineffective • Stress, intravenous dextrose, and enteral feedings, may increase dose requirements for exogenous insulin • Pattern of carbohydrate exposure may change, necessitating pattern adjustment of insulin therapy • Nutritional assessment is important

  16. SLIDING SCALE IS NOT RECOMMENDED

  17. . Prolonged NPO Status

  18. CHOICE OF TYPE AND ROUTE OF INSULIN ADMINISTRATION

  19. CASE Endocrine Follow up • Patient cleared for surgery • Perioperative orders: • Hold standing and supplemental insulin • Give 10u Regular insulin/IV now then • Insulin drip: Plain NSS 100cc + 50 units Regular Insulin – flush 20cc thru the tubings before hooking to patient. Start at 10cc/hr via infusion pump (5u/hr) • CBG monitoring q1h

  20. Objective # 1 Review rationale for intensive glucose control in hospitalized patients and in particular, in surgical patients

  21. 1.What is the rationale for intensive glucose control in hospitalized patients? • Insulin is anti-inflammatory, anti-oxidant, profibrinolytic, anti-platelet, vasodilatory, anti-apoptotic and cardioprotective. • Glucose is pro-inflammatory, pro-oxidant, prothrombotic, platelet pro-aggregatory, worsens prognosis in AMI

  22. Proposed Mechanisms of Poor Outcomes in Patients with Uncontrolled Hyperglycemia • Immune system • Glucose >200mg/dl impairs leukocyte function • Thrombosis • Reduced fibrinolytic activity, increased platelet reactivity • Vascular endothelial dysfunction • Increased permeability, inflammation and thrombosis • Oxidative stress • Cell and tissue injury • Poor wound healing • Glycation of collagen, increased collagenase activity • Insulin deficiency per se Clement S., Braithwaite SS, Magee MF, et al (ADA Diabetes in Hospitals Writing Committee). Management of diabetes and yperglycemia in hospitals. Diabetes Care. 2004;27:533-591

  23. Benefits of Intensive Blood Glucose Control in Critically Ill Patients • Whole blood glucose levels at 80-100% mortality by 34% sepsis by 46% renal failure necessitating dialysis by 41% need for blood transfusion by 50% critical illness related polyneuropathy by 41% Van den Bergh G, Wouters F, et al. Intensive therapy in the critically ill patients. NEJM 2001;345:1359-1367

  24. Increased hormones Cortisol Cathecolamines Glucagon Growth hormone Metabolic effects Gluconeogenesis Glycogenolysis Lipolysis Ketogenesis Metabolic Consequences of Surgery and Anesthesia

  25. Objective # 2 DEFINE INTENSIVE GLUCOSE CONTROL IN HOSPITALIZED PATIENTS AND SET GLYCEMIC TARGETS IN THE SURGICAL PATIENTS

  26. Target Blood Glucose LevelsADA 2006 • Critically ill • BG as close to 110mg/dl as possible and generally <180mg/dl • Noncritically ill • Premeal: 90 – 130mg/dl • Postprandial: <180mg/dl

  27. Glycemic Targets • AACE 80-110 mg/dl • ADA as close to 110 mg/dl as possible, and generally <180 mg/dl • Yale New Haven Hospital 90-120 mg/dl • ACC/AHA ST elevation MI(STEMI) guideline Class I recommendation ”an insulin infusion to normalize BG for patients with STEMI and complicated course “(level evidence B) Class IIa recommendation; :During the acute phase (first 24-48 hours) of management of STEMI inpatients with hyperglycemia, it is reasonable to administer an insulin infusion to normalize BG in paitents with an uncomplicated course “(level evidence B) Garber AJ et al Endocr Pract 2004,10.77-82 ADA Diabetes Care 2006:29 (Suppl 1) 575-77

  28. Objective # 4 REVIEW INTRAVENOUS INSULIN PROTOCOLS CURRENTLY IN USE AND DETERMINE THEIR FEASIBILITY FOR USE IN OUR SETTING

  29. Various protocols • Atlanta Multiplier method • Van den Berghe (studied in critical care setting) • Portland Protocol (used in surgical setting) • Markovitz (studied in post op heart surgery patients) • Yale protocol (studied in medical intensive care setting)

  30. Insulin (units per hour) = multiplier × (BG - 60) With use of this algorithm manually, the initial multiplier is set at 0.02, and a BG value is determined every hour in conjunction with calculation of the units of IV insulin therapy per hour. The multiplier is adjusted every hour by 0.01 to obtain the target BG level—if the result is less than the target, decrease by 0.01; if within target range, no change is needed; if more than the target and the BG level has not decreased by 25%, increase by 0.01. The BG is always determined hourly until stable results are achieved; then it is measured every 2 hours.

  31. Portland Protocol for Continuous IV Insulin Infusion -- FLOOR patientsTarget: 80 - 120 • Surgical Patients: Start “Portland Protocol” during surgery. Continue through 7 AM of the 3rd POD; patients who are not taking enteral nutrition on the 3rd POD should remain on this protocol until taking at least 50% of a soft ADA diet.Medical Patients: Continue Portland Protocol throughout until taking soft ADA diet. • For patients previously undiagnosed diabetes (DM) who present with hyperglycemia: start PDX protocol if blood glucose (BG) level > 150 mg/dl X 2 consecutive readings OR >175 at any one time. Consult endocrinologist for DM workup and follow-up orders. • Start insulin infusion via pump “piggybacked” to normal saline IV as follows: Furnary AP, et al. Endocr Pract. 2004;10:21–33.

  32. Portland Protocol for Continuous IV Insulin Infusion -- FLOOR patientsTarget: 80 - 120 Furnary AP, et al. Endocr Pract. 2004;10:21–33.

  33. Portland Protocol for Continuous IV Insulin Infusion -- FLOOR patients Target: 80 - 120 4.Test BG level by finger-stick or venous line drop sample. The frequency of BG testing is as follows: • If BG ≥180 or < 80 : check BG every 30 minutes • If BG 80 - 179: check BG every hour. • When BG 80 – 120, with <15 mg/dl change and insulin rate remains unchanged x 4hr., = “stable infusion rate” -- then may test q. 2 hrs • May stop q. 2 hr testing on POD #3 in surgery patients or as noted in #1 (see items #1 & #8). • At night: Test q. 2 hr if BG 120 - 150; Test q4 hr if BS 80 - 120 and “stable infusion rate” exists. Furnary AP, et al. Endocr Pract. 2004;10:21–33.

  34. Portland Protocol for Continuous IV Insulin Infusion -- FLOOR patients Target: 80 - 120 5. Insulin titration: 59 Furnary AP, et al. Endocr Pract. 2004;10:21–33.

  35. Portland Protocol for Continuous IV Insulin Infusion -- FLOOR patients Target: 80 - 120 6.7. -- Diet and SQ Humalog orders and titration: SAME AS IN ICU PROTOCOL 8. At protocol cessation: Restart preadmission glycemic control medication. If receiving insulin, wait 1hr after injection of short-acting insulin or 2hr after long-acting insulin before stopping IV insulin drip.Long-acting insulin: type Schedule/dose Short-acting insulin: type Schedule/doseOral agents: • Check BG (circle)….. qAC; qHS; 90minutes PC • OR……….. q ___ hours

  36. GIK Solution • 500ml10% dextrose solution +15u short – acting insulin + 10mmol KCl • Infuse over 5 hours(100ml/h)

  37. CASE CBG MONITORING SHEET Post op Intraoperative

  38. WHEN AND HOW DO YOU INITIATE NUTRITIONAL SUPPORT ?

  39. The time arrives to begin eating discrete meals

  40. 4. How do you shift from IV to SC insulin? • Establish 24 hour insulin requirement • Extrapolated from average over last 4 hours of stable • Give 50% as basal and 50% as total bolus • Correction bolus for BG>140

  41. Shifting Insulin from IV to Subcutaneous Route • Establish 24 hour insulin requirement • Extrapolated from average over last 4 hours of stable • Give 50% as basal and 50% as total bolus • Correction bolus for BG>140 • There should be an overlap between IV to SQ insulin Tx

More Related