Transcript Diabetes and the Surgical Patient

Original Author Tammy Lucht RN CDE
Jeff Worrell, CRNA
Oct 2016
Objectives
1) Compare normal glucose metabolism with that of
type 1 and type 2 diabetes
2) Describe how stress, anesthesia, medications impact
blood glucose levels
3) Describe the perioperative nursing management of
the patient with diabetes
4) Discuss the impact of hyperglycemia on morbidity
and mortality of the surgical patient
Click Here to Play Video
Number (in Thousands) of Hospital Discharges with Diabetes as
Any-Listed Diagnosis, United States, 1988–2009
.
From 1988 to 2009, the number of hospital discharges with
diabetes as any-listed diagnosis increased from 2.8 million to
nearly 5.5 million http://www.cdc.gov/diabetes/statistics/dmany/fig1.htm
Diabetes and Surgery
 25% patients with diabetes will require surgery
 Mortality rates in these patients have been estimated
to be up to 5x’s higher than in patients without
diabetes
 Infections account for 66% of postop complications
and 25% of perioperative deaths
Normal Glucose Metabolism
In pancreas: Beta cells release
insulin in response to glucose rise;
Alpha cells release glucagon when
glucose is low
Glucose Tolerance Categories
2-hr PG on OGTT
FPG
mg/dL
126
100 and <126
<100
Fasting Plasma Glucose
Diabetes Mellitus
Impaired Fasting
Glucose
Normal
Oral Glucose Tolerance Test
mg/dL
200
Diabetes Mellitus
140 and <200
Impaired Glucose
Tolerance
<140
Normal
The Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Diabetes Care.
2004;25(suppl):S5
Goals for Glycemic Control:
FPG, PPG and A1C
Time of Check
Goal
Goal
plasma plasma
blood
blood
glucose glucose
ranges
ranges
for
for
people
people
without
with
diabetes diabetes
Before breakfast (fasting)
Before lunch, supper and snack
Two hours after meals
Bedtime
< 100
< 110
< 140
< 120
70 - 130
70 - 130
< 180
90- 150
A1C (also called glycosylated hemoglobin A1c,
HbA1c or glycohemoglobin A1c)
< 6%
< 7%
http://www.joslin.org/info/goals_for_blood_glucose_control.html
Signs and Symptoms
 Polyuria
 Polydypsia
 Polyphasia
 Wounds slow to heal
 Fatigue
 Blurry vision
 Or~ no symptoms at all
Type 1 v.s. Type 2 Diabetes
Age of onset
Type 1 DM
(< 10%)
< 40
Type 2 DM
(> 90%)
> 40
DKA
Yes
No
Weight
Usually lean
80% overweight
Cause
Autoimmune or No autoimmune
unknown
markers
Pathophysiology of T1DM
antibodies
attack islets!
Pathophysiology of Type 1 Diabetes
Loss of -cell mass
Insufficient
endogenous
insulin
Absolute insulin
deficiency
ADA. Diabetes Care. 2002;25(suppl 1):S1
Pharmacologic Treatment for Type
1 Diabetes
 Type 1= absolute insulin deficiency
 SOME insulin will be required when:
 Carbohydrates are consumed
 To correct for hyperglycemia
 Basal insulin
 Inadequate insulin administration DKA
Multi Dose Insulin Injections
Glargine QD + rapid-acting analog AC
Breakfast Lunch
Insulin Action
Dinner
Glargine
8:00
12:00 18:00
Time
21:00
Insulin Pump
Natural History of Type 2 Diabetes
Relative
-Cell
Function (%)
Glucose
(mg/dL)
350
300
250
200
150
100
50
PPG
Fasting glucose
250
Insulin resistance
200
150
100
Insulin level
-cell failure
50
0
–10
–5
0
5
10
15
20
25
30
Diabetes (yr)
Bergenstal R et al. In: DeGroot L, Jameson J, eds. Endocrinology. 4th ed. Philadelphia, Pa: W.B.
Saunders Company; 2001:821. Originally published in Type 2 Diabetes BASICS (Minneapolis,
International Diabetes Center, 2000). Adapted with permission from International Diabetes Center
(IDC)
Pathophysiology of T2DM
Hepatic glucose output +
Blood glucose
diet
INSULIN
-
Peripheral
Tissue
Uptake
Type 2 Diabetes = Relative Insulin Deficiency
Sites of Action of Currently Available
Therapeutic Options
ADIPOSE
TISSUE
LIVER
MUSCLE
PANCREAS
GLUCOSE PRODUCTION
Metformin
Thiazolidinediones:
Avandia, Actos
INTESTINE
PERIPHERAL
GLUCOSE UPTAKE
Thiazolidinediones
Metformin
Insulin
INSULIN SECRETION
Sulfonylureas: Glyburide, Glimepiride
Non-SU Secretagogues: Repaglinide, Nateglinide
GLUCOSE
ABSORPTION
Alpha-glucosidase inhibitors – slow cho breakdown
GLP-1 agonists : Byetta
DPP4 Inhibitors: Janumet – combo with metformin
Treating Hypoglycemia: Rule of 15
 Give 15 grams of carbohydrate orally if alert
 4 oz juice
 8 oz milk
 4 glucose tabs
 Wait 15 minutes, re-test
 If < 70 mg/dL: re-treat with 15 grams of carbohydrate
 If > 70 mg/dL: give snack if more than 30 minutes
before next scheduled meal
 If not alert: give D50 IV per protocol
Dextrose IV
 D5W = 5 grams dextrose / 100 ml
 D10W = 10 grams dextrose / 100 ml
 D25W = 25 grams dextrose / 100 ml
 D50W = 50 grams dextrose / 100 ml
 4 calories per gram of glucose
 Dextrose is one of two isomers of glucose
Stress, Anesthesia, Medications
Their Impact on Glycemic Control
Perioperative Management
 Surgery impacts BG regulation
 Incisional pain, emotional stress, hypothermia, steroids may
increase insulin needs, decrease insulin sensitivity
 Surgery induces stress response
 Release of catecholamines, glucagon, cortisol
 These all raise BG by stimulating hepatic glucose release and
inhibiting peripheral glucose uptake


Increased need for insulin during surgery
Frequently given by IV drip
 Anesthesia impacts BG
 Inhaled agents may suppress insulin secretion

Regional blocks may decrease this stress response
Hemodynamic, Metabolic, and Neuroendocrine Changes During
Surgery and Anesthesia in Patients With Diabetes
 Release of counter-regulatory hormones (i.e.,
epinephrine, cortisol, growth hormone)
 Tachycardia and tendency to cardiac arrhythmia
 Vasoconstriction and labile blood pressure responses
 Elevated peripheral insulin resistance
 Reduced insulin secretion
 Enhanced hepatic gluconeogenesis
 Decreased peripheral glucose utilization
 Accelerated adipose tissue and protein catabolism
 Electrolyte abnormalities
Rizvi. A, J Am Acad Orthop Surg 2010;18: 426-435
Consensus Recommendations for Target Inpatient Blood Glucose Concentrations
Patient Population
Blood Glucose Target
Rationale
General medical/surgical*
Fasting: 90-126 mg/dL
Random: < 200 mg/dL
Decreased mortality, shorter
length of stay, lower
infection rates
Cardiac surgery*
< 150 mg/dL
Critically ill†
< 150 mg/dL
Acute neurologic disorders‡
80-140 mg/dL
Reduced mortality, reduced
risk of sternal wound
infections
Beneficial effect on shortterm mortality, morbidity;
length of stay
Lack of data, consensus on
specific target; consensus for
controlling hyperglycemia
*American Diabetes Association.
†Society Critical Care Medicine.
‡American Heart Association/American Stroke Association
Steroid Meds Impact on BG Control
Raise BG by increasing glucose release from liver and
decreasing glucose uptake by peripheral tissue
 Steroids that are suddenly decreased can cause
hypoglycemia
 Prednisone: predominant impact is post-meals, taken in
am will persist through afternoon
 Chronic steroid use suppresses stress response and may
lead to severe autonomic derangements unresponsive to
vasopressors

Stat administration of IV corticosteroids may be necessary
What do you need to know about
your patients with diabetes?
 What meds to they take for their diabetes at home or what insulin are
they being given on the floor?
 What they last take and when?
 Insulin : the mainstay of glucose control in hospitalized patients
 Basal insulin: glargine (Lantus)
 Lasts 24 hrs., no pronounced peak, dose may be decreased am of surgery
 Meal time insulin: aspart (Novolog), lispro (Humalog), glulisine (Apidra)
 Lasts 3-6 hrs., peak at 1 ½-2 hours, hold am of surgery
 Correction insulin: aspart
 Given to correct hyperglycemia, not in response to food
 May be given am of surgery
 May be given subcutaneously or IV (regular insulin only)
 Oral agents
 Should be held am of surgery, as a rule
 Will probably not be used for inpatients
 Metformin discontinued 24-48 hours before surgery
Insulin Administration and the Hospital
Insulin pump:
Patient is the best
resource
Initiating An Insulin Drip
1) INSULIN INFUSION: Mix 1 U Regular Human Insulin per 1 cc 0.9 % NaCl.
Administer via infusion pump (in increments of 0.5 U/hr).
PRIMING: Flush 50 cc of Insulin/NS drip through all IV tubing,
before infusion begins (to saturate the insulin binding sites in the
tubing)
2) TARGET BLOOD GLUCOSE (BG) LEVELS: 100-139 mg/dL
3) BOLUS & INITIAL INSULIN DRIP RATE: Divide initial BG level (mg/dL)
by 100, then round to nearest 0.5 U for bolus AND initial drip rate
Example: Initial BG = 325 mg/dL: 325 ÷ 100 = 3.25, rounded ↑ to 3.5:
IV bolus 3.5 U + start drip @ 3.5 U/hr
Considerations
 Timing of surgery
 Morning preferred


To avoid long periods of NPO status
Need q 4-6 hour BG check
 Intra-operative monitoring
 Controlled by anesthesia


IV access makes for easier balance of hypo and hyperglycemia
Frequency determined by type of surgery, length of surgery, pre-op BG trends, age, frailty, etc
 Post-operative monitoring
 BG within range for your institution (generally less than 150 mg/dL)
 Communicate BG readings and treatment in transition of care report
 Document last insulin dose, BG check and communicate to receiving RN
 Aseptic technique is critical
 Decrease incidence of postop infections
 Hyperglycemia is a risk factor of increased morbidity and mortality (with or without a
diagnosis of diabetes)
 Infection causes rise in glucocorticoids, epinephrine and norepinephrine ( increase in
heptatic glucoserise in BG). Makes it much more difficult to control BG!
BG Control:
Impact on Morbidity and Mortality
in Hospitalized Patient
Hyperglycemia*:
A Common Comorbidity in Medical-Surgical Patients in a
Community Hospital
12%
26%
62%
Normoglycemia
Known Diabetes
New Hyperglycemia
n = 2,020
* Hyperglycemia: Fasting BG  126 mg/dl
or Random BG  200 mg/dl X 2
Umpierrez G et al, J Clin Endocrinol Metabol 87:978, 2002
Hyperglycemia: Effect on Length of Stay and
Disposition at Discharge
New
Hyperglycemia
Known
Diabetes
Normoglycemia
Length of stay (d)
9 ± 0.7a, b
5.5 ± 0.2
4.5 ± 0.1
ICU admission (%)
29a, b
14a
9
56a, b
20a
8c
74a
15a
9a
84
10
4
Disposition at discharge
Home (%)
TCU (%)
Nursing home (%)
Results are ± SEM. TCU, Transitional Care Unit
a P < 0.01 vs. normoglycemia; b P < 0.01 vs. Known diabetes
c P < 0.02 vs. normoglycemia
Umpierrez GE et al, J Clin Endocrinol Metabol 87:978, 2002
Hyperglycemia: An Independent Marker of
In-Hospital Mortality in Patients with Undiagnosed
Diabetes
Total In-patient Mortality
Mortality (%)
30
30
16.0% *
20
20
10
0
* P < 0.01
10
1.7%
3.0%
0
Normoglycemia
Known
Diabetes
Umpierrez GE et al, J Clin Endocrinol Metabol 87:978, 2002
New
Hyperglycemia
Blood Glucose Control Matters
 Patients with Diabetes or Hyperglycemia risk higher
complication rates with hospitalization
 Controlling BG before, during and after surgery is
important
 Having a transition of care plan for BG control is
imperative
 If patient is discharging to home:
 When did they last receive insulin?
 When should their next dose be? What kind of insulin?
Documentation, discuss with patient/caregiver
 If patient is going to inpatient setting:
 When did they last receive insulin? What kind?
 Initiate/resume subcutaneous insulin order: this is VITALLY
important for BG control
Resources
 American Diabetes Association
 www.diabetes.org
 American Association of Diabetes Educators
 www.diabeteseducator.org
 Diabetes In Control
 www.diabetesincontrol.com
 American Association of Clinical Endocrinologists
 www.aace.com