Transcript Perioperative Management of - Society of Hospital Medicine

Perioperative Management
of Diabetes
Karrie Berg, D.O., M.A.
Mounting evidence that
perioperative hyperglycemia is
associated with worse outcomes
• Malglycemia causes oxidative stress
• Increased risk of inflammation and infection
• Increased risk of thrombosis
• Many facilities do not have perioperative
protocols or standards
Perioperative Recommendations
• Some evidence based recommendations
• Many expert consensus recommendations
• Do our best to keep the patients safe
Goal
• Help put together evidence-based guidelines
to standardize the perioperative management
of hyperglycemia
• Ensure that surgery patients with transient
perioperative hyperglycemia, impaired
glucose tolerance or diabetes receive optimal
care
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Standardization
Preoperative Screening
Preoperative period
Intraoperative period
Postoperative period
Monitoring
Transitions
Case Study #1
Case Study #2
Questions
Standardize
• Recommendations/ protocols/ order sets
• Develop a team to create recommendations
– Surgeons, anesthesiologists, intensivists
hospitalists, endocrinologist, RNs,
pharmacists, diabetic educators
– People who know national
recommendations and end users
Standardize
• Determine what is currently happening
perioperatively in your facility
– How is the patient educated?
– Is A1C being obtained?
– When is BG being checked / how often?
– Is there intervention for malglycemia?
• Measure before and after
• Create an audit form for evaluation
Pre-Operative Screening
• Check HgbA1C of all diabetic patients
preferably 30 days prior to procedure
• Consider checking A1C for those with a BMI
over 30 or age over 40
Pre-Operative Screening
• Set A1C goals for elective surgeries – no
established cut off point
• A1C can measure glucose control over the
last 3 months
• An elevated A1C can lead to oxidative stress
and poor wound healing
• Consider if it is reasonable for PCP or
Endocrinologist to better manage glucose
prior to surgery (postpone surgery)
Pre-Operative Screening
Suggestions
• Some set target A1c of 8.5 or below
• Will be based on type of patient
– Young pts without comorbidities are
expected to have an A1C closer to 6.5
(tight control)
– Older patients with multiple comorbidities
are allowed to have A1C closer to 8.5
(loose control)
– General control recommendation from the ADA
Patient Education
• Medications to take the day before surgery
• Medications to take the morning of surgery
• Medications to take after returning home or to
the hospital room
• A handout for the patient may be beneficial
• How will patient get this information?
Patient Education
Suggestions
• Type 1 Diabetics
– If on long acting insulin, give 80-100 % of
usual dose prior to surgery
– If on NPH, take 100% of evening dose and
50-75% morning dose
– Specific recommendations should be
recommended by the facility
Patient Education
Suggestions
• Type 2 Diabetics
– Hold oral medications the day of surgery
– Hold non-insulin injectable medications the
day of surgery
Patient Education Example
• Patient Directions
• Patient Directions
Pre-op/ Day of Surgery
• Check blood glucose
• Emotional and physiological stress can cause
hyperglycemia
• Directed change in home medications can
cause hyperglycemia
• Determine if insulin needs to be given prior to
surgery
Set Targets and make plan
• What is your target glucose range?
• What is the plan for hyperglycemia?
– Will you use IV or subcutaneous insulin
– Create a protocol
• What is the plan for hypoglycemia?
– Create a protocol
Set Targets and Make Plans
Suggestions
• BG 100-180 mg/dL
• Tighter control for special populations
(cardiac surgery) 100-150
Hypoglycemia
Suggestions
• If BG is 50-69 mg/dL, give 12.5 gram (25 ml)
D50 slow IV push
• If BG is less than 50 mg/dL, give 25 gm (50
ml) D50 slow IV push
• Recheck FSBG in 15 min
• If no IV access, give glucagon 1 mg IM
Hyperglycemia Treatment
Suggestions
• Blood Glucose
70-180 mg/dL
181-220
221-260
261-300
Subcutaneous Insulin
no tx
1 unit
2 units
3 units
Hyper- and hypoglcemic treatment
• Hyper- and hypoglycemia protocols
• Hyper- and hypoglycemia protocols
Intraoperative
• Determine a plan before the surgery starts
– No longer use sliding scale insulin dosing
– Insulin gtt vs. subcutaneous insulin vs.
basal insulin
• Provide recommendations for insulin use
during surgery -standardize
Intraoperative
Suggestions
• Use subcutaneous insulin to control BG
during short surgeries
• Use IV insulin drip
– for longer surgeries
– type 1 diabetics
– Type 2 diabetics who normally take insulin
• Pts who use basal insulin should have
already received a dose
Intraoperative Protocol
• SHM Perioperative Management\OR Insulin Drip (Draft).pdf
• OR Insulin Drip
Intraoperative
• Create a protocol to transition from IV to
Subcutaneous Insulin
• IV to subcutaneous insulin
• IV to subcutaneous insulin
Postoperative Period
• Many studies show an association between
hyperglycemia in the postoperative period
and adverse outcomes, including infections,
arrhythmias and renal impairment
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Whitcomb et.al (2005)
Freire et. al (2005)
• Some published studies show that
intervention to improve glucose levels reduce
the risk of these complications
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Zerr KJ, et al (1997)
Post-operative Period
• Provide detailed history of BG results and insulin
treatment to be given to the post op RN
• Provide a plan for future treatment
– Transition to oral medications
– Treat with subcutaneous insulin
– Continue IV insulin drip
– Communicate this to care team and patient
• Treat post-operative nausea and vomiting to
promote oral intake
Monitoring
• Blood Glucose (POC) machine available? Or
does sample need to be run to lab?
• Develop a system to record BG, treatment and
time
• Recommended times to check BG
– Upon arrival to pre-op area
– Prior to induction of anesthesia or prior to
incision
– Upon awaking from anesthesia
– On transfer to post-op
Monitoring
• For longer surgeries check BG every hour,
especially if on insulin drip
• Check more frequently if hyper- or
hypoglycemic treatment was required (every
15 minutes)
Transitions
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Very important
Place where many errors occur
Home to pre-op or hospital room to pre-op
Pre-op to surgery
Surgery to recovery
Recovery to hospital room or home
Transition
What to include in handoff
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Did hyper- or hypoglycemia occur?
How was it treated?
How did they respond?
What have the last few blood glucoses been?
What type of monitoring or treatment did they
receive during surgery?
• How frequently is blood glucose being checked?
• What is the plan for medication after recovery?
Standardized Hand-off Form
• Hand-off form
• One form for each transition
• One form showing progress through each
transition
Case Study #1
• 54 yo F with T1DM
• Takes glargine 20 units qhs, lispro 5 units
with meals and 1:20 glucose correction
• Scheduled for a Colonoscopy
• 1 week prior, PCP orders preop labs, gives
handout for preop instructions and gives rx
for bowel prep
• HgbA1C 8.1, H/H 11.2/33.4, K 3.8, creatinine 0.8,
INR 1.1
• Instructions:
– Start Golytle night before procedure
– Clear liquid diet after noon and NPO after
midnight
– Take glargine 16 units the night before (= 80%)
– Take lispro for correction but not nutritional dose
– For Hypoglycemia take 4 oz of orange juice or 2
glucose tabs, recheck in 15 minutes and retreat if
necessary. Tell anesthesiologist of BG and TX
Day of Procedure
• Am BG at home 145 mg/dL
• Upon arrival to surgery center BG 230 mg/dL
• Pt assures anesthesiologist that she took
nothing by mouth this am
• Likely case of stress hyperglycemia
• Pt given 2 units lispro
• Pt taken to procedure room 90 minutes after
arrival
• BG checked prior to sedation 155 mg/dL
• Pt given light sedation
• Procedure takes 20 minutes with 2 polyps
removed.
• Pt taken to post-op
• Anesthesia takes BG prior to handing off to
post-op nurse, BG 145 mg/dL
Hand off report
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On arrival at 0815 BG 230 mg/DL
Pt given 2 units of lispro at 0822
0935 BG155 mg/dL
0940 sedation given
1000 procedure ended
1015 taken to post-op
1017 BG 145 mg/dL
Post-op
• BG checked hourly for the next 2 hours, 127
mg/dL and 146 mg/dL
• Pt awake and ready to return home
Transition to home
• Pt told to resume BG checks at home under
previous schedule, more frequently if
symptomatic
• OK to take lispro correction dose
• OK to take evening glargine dose 100%
• Restart nutritional dose when eating greater
than 50% of meals.
Case Study #2
• 64 yo male with T2DM
• Takes Metformin and Glipizide
• Colorectal surgeon planning for colectomy to
remove a large mass
• 1 week prior he sees the surgeon in the office
who does preop labs and gives him preop
instructions, including diabetes instructions
that the surgeon gives to all his diabetic
patients.
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HgbA1C 6.8, INR 0.9, Hgb 8.2
Bowel prep started the day before surgery
NPO after 2000 (8 pm)
Morning oral medications taken the day
before surgery
• Evening doses held
• Medications held on day of surgery
Day of Surgery
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BG in preop 195
Pt started on insulin drip by anesthesia
IV Bolus of 1.5 units Regular insulin given
IV drip started at 1.5 units per hour
D5 ½ NS was started at 100 ml/hr
Pt taken to OR
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BG checked prior to incision, 145 mg/dL
Infusions remain unchanged
Surgery lasted for 5 hours
BG checks hourly, 162, 141, 153, 128, 136
Pt taken to ICU
• Hand off report given to ICU nurse, including
• BG 195, 162, 141, 153, 128, 136
• Gave 1.5 unit bolus of regular insulin for BG
195.
• Pt remained on insulin drip of 1.5 units per
hour without hyper- or hypoglycemia
• IVF D5 ½ NS at 100 ml/hr
Treatment in ICU
• Pt remained intubated for 24 hours
• Pt remained NPO for 48 hours
• Continued insulin drip and IVF during this
time.
• After 3 consecutive normal BG checks
without changing insulin drip or IVF, BG
checks were changed to q 2 hours
Transition
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Clear liquid diet was started
BG levels increased to 195 and 255 mg/dL
Insulin drip was increased to 3 units per hour
BG stabilized again with hourly checks at 143,
134, 148, 156,132
• Insulin drip was converted to subcutaneous
insulin
• Pt transfer to med/surg floor
• BG and treatment was given to med/surge nurse
Case Study #2 Procedure and
Order Set Usage
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Pt education
Insulin drip protocol- intra-op
Insulin drip ICU
Hypoglycemia procedure
Transition from IV to Subcutaneous insulin
History of treatment report
Questions?
References
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Akhtar S, Barash PG, Inzucchi SE. (2010). Scientific principles and clinical implications of
perioperative glucose regulation and control. Anesth Analg 110:478 –97
American Diabetes Association. Standards of medical care in diabetes—2009. Diabetes Care
2009;32:S13– 61
Drange AS, Perkal MF, Kancir S, Concato J, Aslan M, Rosentahl RA. Long-term glycemic control
and postoperative infectious complications. Arch Surg 2006;141:375– 80
Griesdale DEG, de Souza RJ, van Dam RM, Heyland DK, Cook DJ, Malhotra A, Dhaliwal R,
Henderson WR, Chittock DR, Finfer S, Talmor D. (2009). Intensive insulin therapy and mortality
among critically ill patients: a meta-analysis including NICE SUGAR study data. CMAJ 180:821–7
Joshi G, Chung F, Vann M, Ahmad S et al. (2010). Society for ambulatory anesthesia consensus
statement on perioperative blood glucose management in diabetic patients undergoing ambulatory
surgery. Anesthesia & Analgesia 111: 1378-1387.
Kao LS, Meeks D, Moyer VA, Lally KP. Peri-operative glycemic control regimens for preventing
surgical site infections in adults. Cochrane Database of Systematic Reviews 2009;3: CD006806
Latham R, Lancaster A, Covington J et al. (2001). The association of diabetes and glucose control
with surgical-site infections among cardiothoracic surgery patients. Infect Control Hosp Epidemiol
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Lauruchskat A. (2005). Prevalence and risks of undiagnosed diabetes mellitus in patients
undergoing CABG. Circulation 112(16): 2397-2402.
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References
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Nathan DM, Buse JB, Davidson MB, Ferrannini E, Holman RR, Sherwin R, Zinman B (2009)
American Diabetes Association, European Association for Study of Diabetes Consensus
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the initiation and adjustment of therapy: a consensus statement of the American Diabetes
Association and the European Association for the Study of Diabetes. Diabetes Care 32:193–203
Pichardo-Lowden A, Gabbay, RA (2012). Management of hyperglycemia during the perioperative
period. Curr Diab Rep 12: 108-118
Polk HC Jr. Renewal of surgical quality and safety initiatives: a multispecialty challenge. Mayo Clin
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