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Perioperative Management Diabetes Mellitus Adrenal Insufficiency

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.

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Perioperative Management Diabetes Mellitus Adrenal Insufficiency

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  1. Perioperative Management Diabetes MellitusAdrenal 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, 159:2405-2411, 1999. • Inpatient Management of Adults with Diabetes. Diabetes Care. 18:870-878, 1995. • Perioperative management of diabetes mellitus. www.uptodate.com, Dec 18, 2001.

  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: 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

  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)

  7. 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

  8. 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)

  9. Insulin

  10. 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.

  11. 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.

  12. 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

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

  14. 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

  15. 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

  16. 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

  17. 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

  18. 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 [ ] Non-caloric beverage

  19. 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 IV D5W gtt @ 75-100 cc/h > 20.0 Check urine ketones, consider postpone OR

  20. 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.

  21. SC Insulin Supplemental Scale

  22. 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

  23. 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

  24. Surgeon: ? Internal Medicine: ? Endocrinologist: ?

  25. 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

  26. 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)

  27. 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

  28. 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?

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

  30. 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

  31. 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

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