Transcript Perioperative Care of the Person with Diabetes

Perioperative Care of the Person with
Diabetes
Alison Gebuehr
CNC Diabetes
JHH
Credentialled Diabetes Educator
Adapted from presentation by Hilary Fejsa
21st October 2011
Things to Consider
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Why do we need to bother
Risks of Surgery
Pre Operative Considerations
Planning Care
– Type 1
– Type 2
– Other factors
– Pumps
• Post Operative Care
Perioperative Care of the Person with Diabetes
Rationale
– 25% of pts with diabetes will require surgery
– Periop mortality rates up to 5x greater than nondiabetics
– Random BGL > 11.1mmol- general med / surg pts
18
fold increase in in-hospital deaths, longer length of stay &
greater risk of infection
– DM accounts for nearly ¼ of all perioperative deaths
– Infections account for 55% of postop complications
– DM is independent predictor of postop MI
Goals of Surgical Management
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Maintain glycaemic control
Prevent hypoglycaemia
Prevent marked hyperglycaemia
Prevent ketoacidosis
Prevent electrolyte and fluid imbalance
Prevent postoperative complications
Factors Affecting Diabetes Control with Surgery
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Stress and anxiety
Fasting state
Anaesthesia
Current diabetes control
Chronic diabetes complications
Other medications
Risks of Surgery for Diabetic Patients
• Hyperglycaemia
– Stress, fear, pain, anxiety, causative illness, infection, drugs
• Hypoglycaemia
– Fasting, postop nausea, vomiting
• Potential for DKA, hyperosmolar coma, lactic
acidosis
• Increased risk of postoperative complications
– Poor healing, infections, increased risk of thrombosis
• Exacerbation of pre existing comorbidities
– Cardiovascular
The Perfect Patient
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Planned procedure vs emergency
Good control (HbA1C <7%)
Insulin or medication regime stable
Educated about risks and expectations
Reviewed medically (either by GP or
Specialist) prior to procedure
• Stable Comorbidities
Pre-op Planning
Where possible, pt should have a preprocedural assessment to assess
diabetes management, complications,
co-morbidities, and to prepare a
management plan
Pre-op Planning
• Questions to ask ? –
• What type of diabetes do they have - type 1 or type 2
• How do they treat their diabetes- insulin, oral
hypoglycaemic agents or lifestyle
• What type of procedure- major, minor, gut surgery,
anticipated recovery time, anticipated post operative
complications for individual patients, emergency or planned
surgery.
• When is the procedure- morning or afternoon
Pre-op Planning
• Pre-op control- good or poor control, stability of
existing comorbidities, nutritional status
• What things will influence post-op recovery
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Nutrition
Wounds
Recovery time
Drugs needed (e.g steroids)
Infection
• Do they need to improve control prior to surgery
Lets look at our different
groups of patients!
Planning Care – Lifestyle Or Oral Agents
• Fast as advised by pre-operative clinic or
anaesthetist.
• Stop oral agents as advised. Biguanides (eg
Metformin) should be ceased at least 24 hours prior
to surgery to decrease risk of lactic acidosis. Be
aware of combination drugs containing Metformin.
• Other oral agents- omit day of surgery
• Unplanned surgery – check renal function, hydrate
well if on Metformin.
• Take other medications (blood pressure
drugs etc) on day of surgery.
Planning Care – Lifestyle Or Oral Agents
• Test blood glucose levels prior to surgery and as required
during surgery
• More frequently if poor control prior to surgery, major
surgery, unplanned surgery.
• Pre-op –
• If BGL < 5mmol- may need IV Dextrose or clear juice
(no pulp) if greater than 2 hrs till surgery time
• If BGL > 10mmol- consider commencing insulin infusion
• Consider insulin/dextrose infusion if BGL’s unstable or major
surgery.
• Review by team as needed
Planning Care - Insulin Treated
• Type 1 or Type 2
• Can be on a combination of insulin and oral therapy
(eg Metformin)
• May need insulin/dextrose infusion – dependent on
type of surgery
• Pre and post op planning based on current insulin
regime
Basal Insulin
• Need 50 –70 % of total insulin for BASAL needs
• Normal daily activity – keep body running
• Prevents ketosis and loss of diabetic control
Planning care - Insulin Treated
• Fast as advised by pre-operative clinic or anaesthetist
• Take other medications (blood pressure drugs etc) on day of
surgery.
• Insulin as per next slide
• Test blood glucose levels prior to surgery and as required
during surgery
• More frequently if poor control prior to surgery, major surgery,
unplanned surgery.
• Pre-op –
• If BGL < 5mmol- may need IV Dextrose or clear juice (no pulp) if
greater than 2 hrs till surgery time
• If BGL > 10mmol- consider commencing insulin infusion
• Consider insulin/dextrose infusion if BGL’s unstable or major
surgery.
• Review by team as needed
Insulin Regimes
• Long acting once day
– if nocte, usual dose evening before
– If mane, half of normal dose at usual time
• Pre-mixed Insulins (mane or BD)
– Give half of normal morning dose of insulin at usual time
• Basal Bolus with evening long acting insulin
(PM dose of long acting insulin and short acting doses with meals)
– Give normal dose long acting in the evening before surgery
– Withhold short acting doses while fasting on day of surgery
• Basal Bolus with mane long acting insulin
(AM dose of long acting insulin and short acting doses with meals)
– Give half of morning dose of long acting insulin on morning of surgery
– Withhold short acting doses while fasting on day of surgery
• Other Regimens (including insulin pump therapy) seek specialist
advice
Planning Care - Insulin Treated (major procedure)
• Insulin dextrose infusion should be commenced
when fasting
• Use 5% Glucose at 125mls/h – provides basal energy,
prevents ketosis, prevents hypo’s.
• Titrate insulin to blood glucose levels using
appropriate algorithm – algorithm used is based on patients
usual insulin dose
• Hourly BGL’s
• Start back on normal insulin regime
when able to eat normally and blood
glucose control is acceptable.
Insulin infusion algorithms
Algorithm 1 Algorithm 2 Algorithm 3
Algorithm 4
Usual dose Usual dose Usual dose
Usual dose
Blood Glucose 20 - 50 u/day 50 - 100u/day 100 - 150u/day > 150u/day
<3.8
Call Endocrine team
3.8 - 6.0
0.2
0.5
1
1.5
6.1 - 6.6
0.5
1
2
3
6.7 - 8.2
1
1.5
3
5
8.3 - 10.0
1.5
2
4
7
10.1 - 11.6
2
3
5
9
11.7 - 13.3
2
4
6
12
13.4 - 14.9
3
5
8
16
15.0 - 16.6
3
6
10
20
16.7 - 18.2
4
7
12
24
18.3 - 19.9
4
8
14
28
>20
Start at 6.0 to 12.0 units per hour and call Endocrine team
Insulin Pumps
• Patient is the expert
• Not to be disconnected unless patient is
receiving insulin
• Should be removed during CT scans etc
• Should be protected from accidental
disconnection
Insulin Pumps
• Minor Procedure
– Patient should be able to
manage pump
– Leave on at basal rate
– Resume bolus when eating
• Major Procedure
– Disconnect pump treat as for major procedure on
basal bolus insulin
Post Operative Care (All Patients)
• Resume normal meals, insulin/medications as soon
as possible
• May need close monitoring for post operative
complications – infection, poor healing, thrombosis,
worsening of comorbidities
• May need adjustments to normal treatment (short or
long term) depending
on prior control, new medications,
post operative problems
Post Operative Care (All Patients)
• REMEMBER!!!
• Very important to maintain tight control in immediate
post-op period
• Aim BGL 5-10mmol
• to reduce post-op complications
• Aid wound healing
• Reduce risk of infection
• First 24- 72 hours crucial
Assessing the patient
• Have they had education and when?
• How do they manage at home?
• Is their current problem going to impact on their
management?
• Has their management changed due to their condition?
• Do they need dietary advice?
• Do they need specialist input?
• Do they need ongoing education?
• Will they be able to cope at home?
• Are other services needed?
NEVER LET A CHANCE GO BY
ALWAYS
Assess knowledge of diabetes self
management and need for further
education.
Organise appropriate follow up if needed
with diabetes educator, endocrinologist,
podiatrist etc
Bibliography
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Moghissi, ES, Korytkowski, MT, DiNardo, M, et al.
AACE and ADA consensus statement on inpatient glycemic control. Diabetes Care 2009.
32:1119
Smiley, DD, Umpierrez, GE
Perioperative glucose control in the diabetic or nondiabetic patient. South Med J 2006;
99:580
Mantz, J., Dahmani, S, Paugam-Burtz, C. 2010.
Outcomes in perioperative care. Curr Opin Anaesthesiol; 23:201-208
Lipshutz, A, Gropper, M. 2009.
Anaesthesiology: 110:408-21
Ramos, M, Khalpey, Z, Lipsitz, S., Steinberg, J., et al. 2008.
Relationship of Perioperative hyperglycemia and postoperative infection in patients who
undergo general and vascular surgery. Annals of Surgery. Vol 248: 4. 585-591
Noordzij PG, Boersma E, Schreiner, F, et al. @007.
Increased preoperative glucose levels are associated with perioperative mortality in patients
undergoing noncardiac, nonvascular surgery. Eur J Endocrinol.2156:137-142.
Akinbami, F, Askari, R., Steinberg, J., Panizales, M., Rogers WO Jr..2011.
Factors affecting morbidity in emergency general surgery. Apr. 201
Edelson GW, Fachnie JD, Whitehouse FW.
Perioperative management of diabetes. Henry Ford Hosp Med J 1990;38: 262-265