Transcript Medical Procedures and Diabetes

Preparing for Medical Procedures
for Patients with Diabetes
Elizabeth Duke Gibbs RD, CDE
Jennifer Shaver RN, CDE
Diabetes Education and Management Centre
Hotel Dieu Hospital
November 13, 2015
Objectives

Preoperative glycemic control

Non- insulin antihyperglycemics and fasting

Adjustments of insulin for fasting
procedures/surgery

Diabetes issues related to medical procedures

SADMANS
The focus around surgery/medical procedures for
those with diabetes is to avoid:

Hyperglycemia/Hypoglycemia

Diabetes Ketoacidosis (DKA)/Hyperosmolar
Non-Ketotic State (HHNK)

Sepsis
Kadoi,Y. J Anesth. (2010) 24:739-747
Preoperative Glycemic Control

Numerous studies have shown that poor
preoperative glycemic control is associated with
adverse clinical outcomes including:
increased mortality, morbidity, delayed wound
healing and postoperative infection.
(Kaczynski, et al (2010) 20: 411-413
Uncontrolled DM results in an increase of surgical
and systemic complications


Length of hospital stay is higher among people
with diabetes
Infections cause 2/3 of postoperative
complications and is the principal cause of 20%
of postoperative deaths among persons with
diabetes.
Non insulin Hyperglycemics and
Fasting Type 2 DM

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Important to assess the medications that the
patient is on prior to surgery
May need to stop antihyperglycemics pre-op
based on duration of action.
Class
Agents
Biguanide
Metformin
12-24
Last meal prior to the
onset of fasting
Incretins
Byetta
4-6
Last meal prior to the
onset of fasting
Victoza
24
24 h prior to the onset
of fasting
Sulfonylureas Glyburide
Duration of action(h)
16-24
Last dose should be
taken no later than ..
24 h (occasionally 36 h)
prior to the onset of
fasting
DPP4
Januvia/Onglyza 24
24 h prior to the onset
of fasting
Meglitinides
Gluconorm
Last meal prior to the
onset of fasting
4-6
Grajower,M (2011) Diabetes Metab Res Rev (27): 413-418

If a patient's glycemic control is not at target
despite being on non-insulin antihyperglycemics
diabetes medication, they may need to go on
insulin prior to surgery

Grajower, M (2011) Diabetes Metab Res Rev 27:413-418
Adjustments of Insulin(s) for Fasting
Procedures/Surgeries
BASAL INSULINS
Long acting – Lantus, Levemir, NPH
• PM- basal insulin dose-usual dose EXCEPT if
hypoglycemia has been an ongoing issue. If this
is the case, the dose can be decreased by 25%
• AM- basal insulin dose-give 1 /2 dose if in
optimal control pre-admission, to 2/3 if not in
optimal control
KGH Diabetes Management Peri-op/procedure Order Set
Premixed insulin-30/70, 25/75, 50/50
PM- Administer usual dose evening before
procedure
AM –Give 1/3 of the pre-mixed insulin dose as NPH
( to represent 50% of basal portion of AM dose)
the morning of procedure
KGH Diabetes Management Peri-op/Procedure Order Set (Adult)
KGH and HDH policy is to:

hold all oral diabetes medications am of surgery

hold am prandial insulin.

basal insulin adjustments as specified by
anaesthetist
Checking Blood Glucose Morning of
Surgery/Procedure.
HyperglycemiaPatients using a supplemental insulin scale
with rapid insulin can apply it to correct a blood
glucose above 11 mmol/L
Dobri, G & Lansang, MC . Cleveland Clinic Journal of Medicine ( 2013) 80: 702-704
HypoglycemiaIf blood glucose is < 4 mmol/L , give 125 ml (1/2
cup) of apple juice or non-diet pop ( no milk,
honey or fruit juice containing pulp) and recheck
BG in 15 minutes.
If BG still <4 mmol/L repeat treatment.
CHEO Physician Orders for Management of Patients with DM treated with Insulin Injections Short Procedures (<2
hours)
Pre surgery –Pumps /Sensors


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Patient must bring all insulin pump supplies to the
hospital
If procedure < 2 hours – continue usual basal rate
settings overnight and day of surgery.
If procedure > 2 hours – will likely transition to IV
insulin – pump should be discontinued 30
minutes after IV insulin is started.
KGH Diabetes Management Peri-op/procedure Order Set
Post surgery- Pumps/sensors
At KGH there is a “Patient Self-Management of
Insulin Pump Consent Form” detailing the
requirements that need to be met in order for a
patient to continue to wear their pump in hospital
KGH Policy 14-102 Appendix A
DISCONNECT PUMP FOR:

Pacemaker/Implantable Defibrillator

Cardiac Catheterization

Nuclear Stress Test

Bone Density Scan

Fluoroscopy - Therapeutic Radiation ( cancer)

CT/MRI Scan

Electric-cautery surgery

General Anesthesia ( depends on equipment being used
during surgery)

Mammogram

Body/Dental x-rays
Insulin Pump and CGM System Owner’s Booklet
No need to disconnect for :
•
EKG
•
Ultrasound
•
Laser Surgery ( some lasers can cause pump to alarm)
•
Colonoscopy
Insulin Pump and CGM System Owner’s Booklet
https://www.youtube.com/v/Kdgyjdt03Tg
Diabetes issues related to medical
procedures -Colonoscopy Bowel Prep
Guidelines
Two main considerations are getting enough fluids and
carbs:
FluidsThe goal is to drink at least one tall glass of fluid every hour
the day before the procedure. Non-carb fluids
to choose from are water, clear broth, sugar-free ginger
ale, sugar-free popsicles, sugar-free Jell-O, clear teas.
There is no restrictions on the clear no carb fluids.
Patient Information Brochure HDH for Colonoscopy( 2015)
CarbohydratesIn addition to fluids a patient must meet their needs
for carbohydrate every hour. See the list below for
the drink ideas and portion sizes for your hourly
need during waking hours.
Patient Information Brochure HDH for Colonoscopy( 2015)
List of fluids containing carbs: ( approximately 10 grams)
1/3 cup of apple juice
½ cup of regular ginger ale/ sprite/7-up or
other caffeine- free clear pop)
¼ cup regular Jell-O ( yellow only)
¾ regular popsicle NOT red, purple, green
or chocolate
Two hard candies
Patient Information Brochure HDH for Colonoscopy( 2015)
Diabetes issues related to medical
procedures
METFORMIN should be temporarily discontinued 48
hours before undergoing radiologic studies involving
intravascular administration of iodinated contrast
materials, because use of these may result in acute
alterations of renal function.
Metformin should be restarted 48 hours post
procedure if the eGFR and creatinine are confirmed to
be normal.
Metformin Monograph
CPG 2015 SADMANS GUIDELINES

S = Sulphonylureas

A = ACE inhibitors

D = Diuretics, direct renin inhibitors
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M = Metformin

A = Angiotensin receptor blockers
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N = Non-steroidal anti-inflammatory

S = SGLT2 inhibitors
Instructions for Healthcare Professionals:
adequate fluid intake, or have an acute decline in
renal function (e.g. due to gastrointestinal upset or
dehydration), they should be instructed to hold
medications which will:
• Angiotensin-converting enzyme inhibitor
• Angiotensin receptor blockers
• Direct renin inhibitors
• Non-steroidal anti-inflammatory drugs
• Diuretics
• SGLT2 inhibitors
B) Have reduced clearance and increase risk for
adverse effects:
• Metformin
• Sulfonylureas (gliclazide, glimepiride, glyburide)
S sulfonylureas
A ACE-inhibitors
D diuretics, direct renin inhibitors
M metformin
A angiotensin receptor blockers
N non-steroidal anti-inflammatory
S SGLT2 Ifinhibitors
patients become ill and are unable to maintain
Please complete the following card and give it to
your patient.
Patients should be instructed that increased
frequency of self blood glucose monitoring will be
required and adjustments to their doses of insulin or
oral antihyperglycemic agents may be necessary.
Instructions for Patients
When you are ill, particularly if you become dehydrated
(e.g. vomiting or diarrhea), some medicines could
cause your kidney function to worsen or result in
side effects.
If you become sick and are unable to drink enough
fluid to keep hydrated, you should STOP the following
medications:
• Blood pressure pills
• Water pills
• Metformin
• Diabetes pills
• Pain medications
• Non-steroidal anti-inflammatory drugs (see below)
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Please be careful not to take non-steroidal antiinflammatory drugs (which are commonly found in
pain medications (e.g. Advil) and cold remedies).
Please check with your pharmacist before using overthe-counter medications and discuss all changes in
medication with your healthcare professional.
Please increase the number of times you check your
blood glucose levels. If they run too high or too low,
contact your healthcare professional.
If you have any problems, you can call:
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THANK-YOU FOR YOUR ATTENDANCE AND
ATTENTION!