peri-operative diabetic patient management larry field, md critical care anesthesiologist medical...
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Peri-Operative Diabetic Patient Management
Larry Field, MDCritical Care Anesthesiologist
Medical University of South CarolinaApril 20, 2010
Objectives• Update our knowledge of different
insulin preparations• Update our knowledge of non-insulin
(oral and injectable) agents• Set reasonable goals for perioperative
glycemic control• Suggest recommendations for
achievement of glycemic goals
• Disclaimers: None
Diabetes Mellitus
• Metabolic diseases characterized by hyperglycemia resulting from defects in insulin secretion, insulin action, or both
• Affects 8% of general population
• 20% of persons aged 65 to 74
• 30-40% of those born this past decade
JAMA 2003;290:1884–90
Curr Opin Anaesthesiol 22:718–724
Alpha-glucosidase inhibitors
• Acarbose (Precose), miglitol (Glyset)
• Inhibit oligosaccharide and disaccharide uptake at intestinal (brush border) level
• If NPO, doesn’t do anything
Biguanide• Metformin (Glucophage)
• Inhibition of gluconeogenesis in the kidneys and liver
• Bind to the Mitochondrial membranes, leading to decreased ATP and increased AMP• Limited hypoglycemia potential• Lactic acidosis black box warning• Classically hold for 48hrs
• Eliminated by kidneys
Sulfonylureas
• Endogenous insulin release from beta cells• Can cause
hypoglycemia• Hold on morning of
surgery
www.endotext.org
Meglitinides
• Nateglinide (Starlix), repaglinide (Prandin), repaglinide/metformin (PrandiMet)
• Induce endogenous insulin release similar to sulfonureas• Hypoglycemic risk reduced?
• Quick/short action • Taken prior to each meal
Thiozolidinediones (glitazones)
• Troglitazone (Rezulin), rosiglitazone (Avandia), pioglitazone (Actos)
• Transcription factor (PPAR)agonist
Insulin receptor sensitization
• Also improves lipid profiles
• No lactic acidosis
• Limited potential for hypoglycemia
• Hepatotoxicity and fluid retention concerns
• Short plasma half-life; Long duration of action
Incretin hormones?
• GI hormones released in response enteral carbohydrate load
• Glucose-dependent insulinotropic polypeptide (GIP)• Increased insulin release from beta cells
prior to hyperglycemia
• Glucagon-like peptide 1 (GLP-1)• Neuroendocrine signal
GLP-1• Alpha cells:
• Glucose-dependent glucagon inhibition
• Beta cells:• Primes glucose-dependent insulin
release• Increases beta cell numbers• Increases insulin biosynthesis
• Reduces appetite; slows gastric emptying
Dipeptidyl peptidase IV
• Ubiquitous
• Involved in hormone degredation• GLP-1, VIP, GHRH, neuropeptide Y• GLP-1 is quickly degraded
• Involved in immune cell messaging
Amylin
• Produced by pancreatic beta cells similar to insulin
• Independent/additive effects to insulin
• Glucose-dependent glucagon suppression
• Satiety and delayed gastric emptying
Newest Agents
SQ
PO
SQ
Anesth Analg 2009;108:1803–10
Little anesthetic experience with these agentsBased on physiology and pharmacology
Surgery as a Metabolic Challenge
• Stress hormones – catecholamines, cortisol, growth hormone
• Cytokines – IL-6 and TNF-alpha
• Hyperglycemia proportional to insult• Superficial: 10-20 mg/dl• Major vascular/cardiac: 50-100 mg/dl
Stress-induced hyperglycemia
• Adaptive response• Brain and red blood cell uptake is
increased
• Independent risk factor for morbidity and mortality
Hyperglycemia
• Impaired collagen production
• Impaired neutrophil chemotaxis, phagocytosis, and bacterial killing
• Increased platelet aggregation
• Infectious complications
Clinical Diabetes 2009; 27:82-85
Hypoglycemia
• Sympatho-adrenal activation
• Diaphoresis, tachycardia, hypertension
• Weakness/fatigue AMS Coma
• Common in Type 1 diabetics
• Uncommon in Type 2 diabetics
Intraoperative Glucose Control Data
• Sparse data on outpatient procedures
• Critical care data• Van den Berghe 2001 80-110 goal• NICE-SUGAR 140-180 goal
• Cardiac/surgical data
• Very tight vs good vs poor glucose control
Insulin Benefits
• Decreases endothelial activation
• Improved lipid profiles
• Decreases pro-inflammatory cytokine production
• Benefits thought due to glycemic control
Treatment Goal
• Try to mimic normal metabolism as closely as possible:• Avoiding hypoglycemia• Avoiding excessive hyperglycemia• Avoid ketoacidosis • Avoid electrolyte/fluid disturbances• Avoid large fluctuations
Consensus Recommendations
Typical daily insulin regimen
(DM Type 1: about 50% of daily insulin is basal)
Consensus Statement, SAMBA 2010
POC testing can be off by +/- 20%• 20% of capillary
• 7% of whole blood samples
Mayo Clinic Proc. 2008; 83:394-397
Consensus Recommendations
Consensus Statement, SAMBA 2010
Insulin admin: IV gtt vs IV bolus vs SQ bolus?
• Use 1500 rule for regular insulin
• Use 1800 rule for rapid-acting insulin
Current opinion in anesthesiology 2009; 22:718-724
Insulin Dosing
Other Anesthetic Considerationsfor Diabetes Mellitus
• Diabetic comorbidities not covered today
• Periop/stress steroids
Hyperglycemia within a couple of hours
• Starvation increases insulin resistance
Preop carb loading may help
• Beta-blockers can blunt catecholamine-induced hyperglycemia
Other Anesthetic Considerationsfor Diabetes Mellitus
• Etomidate can blunt steroid-induced hyperglycemia of stress
• Volatile anesthetics impair insulin release and increase insulin resistance (dose-dependent)
• Regional anesthesia/local anesthetics can blunt/abolish periop hyperglycemia
• High-dose opioids also blunt
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