Conflict of interest

2. Conflict of interest Type 1 diabetes >20 years - age 23 Pens: -Aspartate insulin (Novorapid): GM human; 3 X 12 units -Glargine (Lantus): GM human: 36 units nocte -BSL – Glucometer 5 seconds: digital + log Gerich, Am J Med, 2002

3. Topics: • New role for HbA1c • New insulins • Perioperative glucose control

4. Frequency perioperative diabetes REASON study 4,150 older inpatients 23 hospitals ANZ 22% diabetes, 30-day mortality 5% (OR 1.0) -27% IHD (20% all) -26% CRI (16% all) Story et al, Anaesthesia, 2010

5. Diabetes diagnosis • Random BSL >11mmol/L • Fasting BSL ≥ 7 mmol/L • OGTT 2hr BSL >11mmol/L • Diabetes likely • Diabetes unlikely • Impaired glucose tolerance, >5.5 mmol/L Diabetes Australia + RACGP, Diabetes Management, 2009

6. Diabetes “severity” Using haemoglobin A1C: HbA1c “A1C” Hb + glucose irreversibly attached to beta chain A1C - 3 months; <30 days 50%, 60 to 120 days 25% A1C Mean BSL 6% 7.5 mmol/L 7% 9.5 mmol/L 8% 11.5 mmol/L 9% 13.5 mmol/L 10% 15.5 mmol/L Burtis et al, Tietz Textbook Clinical Chemistry, 2006

7. Diabetes Care, 2009 Not acute Type 1 RBG > 11 mmol/L diagnostic Endorsed by Diabetes Society of Australia

8. A1C ≥6.5% DM, 6.0% to 6.4% Intolerance Diabetes Care, 2009

9. Flinders 2009 11% (262/2360) undiagnosed 666 surgical patients 52 (8%) known diabetes 54 (8%) unknown diabetes Medical Journal of Australia 2011

10. Surgery, A1C and infection 490 diabetic patients, non-cardiac VA Conneticut Median age 72, median A1C 7.3% A1C < 7.0%, n= 197, infection 12% A1C ≥ 7.0%, n= 293, infection 20% Adjusted OR A1C ≥ 7.0%, infection OR 2.1 (1.2 to 3.7) Dronge et al, Arch Surg, 2006

11. Ann Thorac Surg, 2009

12. New Insulins Killen et al, Anaesth Intensive Care, 2010

13. Basal rapid acting infusion + boluses Insulin Pumps Killen et al, Anaesth Intensive Care, 2010

14. Hypoglycemia Variation between and within US mg/dl = mmol/L X 18 approx 20 200mg/dl = 11.1 mmol/L (approx 10 mmol/L) Reference Range: 4 mmol/L to 6 mmol/L 3 mmol/L – sympathetic – sweating, hunger 2.5 mmol/L – altered CNS: confusion, diplopia Eventually coma, death Service, NEJM, 1995

15. Perioperative diabetes • Limited evidence Glister + Vigersky, Endocrinol Metab Clin N Am, 2003 • Ask patient: “What and when” - sugar and insulin • Three parts: -Basal: glargine – avoids ketosis (cf GIK) -Nutritional – rapid (W/H) -Corrective –rapid s/c or IV regular Assundi + Calles-Escandon, J Hosp Med, 2007 Killen et al, Anaesth Intensive Care, 2010

16. Dumb things with insulin • Forget to take it • Take twice • short • long • Take wrong one • Take too much • Eat too much for usual dose • Eat too little for usual dose Unusual and/or stressful situations

17. Insulin pumps Beware: Technology + no underlying long acting Options: • IV regular infusion at basal rate (day surgery) • Continue with pump if confident • Convert to s/c rapid + glargine Assundi + Calles-Escandon, J Hosp Med, 2007 Killen et al, Anaesth Intensive Care, 2010

18. Perioperative diabetes Measure the blood sugar

19. What BSL? Aim: 8 mmol/ L (5 to 10 mmol/L) NICE-SUGAR: 6000 ICU patients 4.5 to 6.0 mmol/L (tight) vs <10 mmol/L (usual) 90 day mortality, Tight control surgical OR: 1.31 Hypos 6.8% vs 0.5% NICE-SUGAR Investigators NEJM, 2009

20. Hypo…how much dextrose? • Mild to mod: 3 to 5 mmol/L; severe < 3 mmol/L • Don’t over treat: target 8 mmol/L (5 to 10 mmol/L) • Dextrose 5% = 5 g/100ml • Dextrose 50% = 50 g/100 ml = 5g/10 ml IV push • BSL 3-5 Dose = 0.1 g/kg 2ml/kg 5% dextrose • BSL < 3 Dose = 0.15 g/kg 3ml/kg 5% dextrose Can’t remember = 150 ml 5% Dextrose (7.5g) = 15 ml 50% Assundi + Calles-Escandon, J Hosp Med, 2007

21. You can drink D5W …but the taste isn’t great

22. Why is the patient hypo? • Poor management: eg delay • Mistake in insulin or intake? • Is the problem fixed? • beware duration too much long-acting • Beware insulin infusions

23. Most likely…hyperglycemia My glucometer on Christmas day…

24. Most likely…hyperglycemia • BSL > 10 mmol/L • Hours: unpleasant hyperosmolar, dehydrated • Don’t over treat; target 8 mmol/L (5 to 10 mmol/L) • 80/total daily insulin = 1 unit effect mmol/L BSL • Me: 72 units / day 80/72 = 1.1 mmol/L for 1 unit Adult rule of thumb: BSL - 8 = IV regular insulin OR S/C rapid Glister + Vigersky, Endocrinol Metab Clin N Am, 2003

25. Then 15 minutes later… Measure the blood sugar

26. Postop • Physicians • Three parts (alternative to insulin infusion) • 0.5 units / kg / day (conservative start) -Basal: glargine 0.25 units / kg / day -Nutritional –rapid s/c 0.25 units / kg / day -Corrective – rapid s/c • RABBIT 2, Diabetes Care 2011 Assundi + Calles-Escandon, J Hosp Med, 2007

27. Higher A1C less tolerant of lower glucose Egi et al, Crit Care Med, 2010

28. Acclimatization

29. Concluding thoughts… Balance of probabilities: • A1C in all coronary + vascular patients • ?A1C in others eg 70+ • No DM + A1C >6% - med review – risks • A1C >8% +/- DM - med review Research: A1C in ANZ populations: complications :RCT usual care vs A1C < 7.0 preop Measure the blood sugar

30. Concluding thoughts… • No evidence for very tight control in OR • Aim: 8 mmol/L (Range: 5 to 10 mmol/L) • Give basal • W/H rapid • Don’t overreact • Use IV regular or s/c rapid to correct • Beware pumps • Antiemetics • D5W is our friend • Endocrine involvement for O/N stay Measure the blood sugar Ahmed et al, AnaesthAnalg, 2005

31. You forgot to measure the blood sugar?!? Thanks