preoperative diabetes evaluation in vascular surgery...

Preoperative Diabetes Evaluation in Vascular Surgery Patients

May 24, 2019

DISCLOSUREEdie Shen, MD

• No relevant financial relationship reported

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Diabetes and Vascular Disease

Glucose Target 100-180⬆ Mortality⬆ Composite Infec4on rates⬆ Re-opera4on

Perioperative Glucose Management

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Predictors of Amputation Despite Patent Bypass Grafting

• CLI with autologous vein graft

Smith et al. Journal of Vascular Surgery. May 2016. Volume 63, Issue 5, Pages 1279–1288

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Preoperative Evaluation

•A1c data is variable

•Can consider delaying elective surgery for A1c 8.5 or even 8

King. Ann Surg 2011; 253:158-65

Vascular Patient Postop Infections

•Mean 24 h Blood glucose postoperatively significantly increased SSI and total Infx

8Vriesendorp. Eur J Vasc Endovasc Surg 2004; 28:520-5

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Risk Reduction with DOS Insulin

Kwon et al. Annals of Surgery. 257(1):8–14, JAN 2013

Insulin reduces risk even when glucose control is not as good as desired.

Patch Dellinger MD

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Clinic Preoperative Education Type 2 DM

-Checking blood sugars at home

-Medical Nutrition Therapy- no single diet

-Mediterranean diet-low carb-DASH-Lean Cuisine 45-60 g carbs

- A wide range of physical activity, including leisure time activities (e.g., walking, swimming, gardening, jogging, tai chi, and yoga) can significantly reduce HbA1c

Davies et al. Diabetes Care 2018 Sep

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Low Carb Diet Pyramid

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Preoperative Glucose Case ManagementDawn Corl RN MN CDE: April–December 2018

• n=28 patients A1c > 8.5• Counseling regarding nutrition,

insulin titration, dry run• 12 / 28 patients completed • 4 patients ⬇A1c avg 1.7%• DOS fasting glucose average

improved

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153

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65

130

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DOS fasting glucose

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Basic Principles DOS•Hold ALL Oral diabetes medicines and all short-acting insulin

•Type I DM: continue 80-100% of long-acting insulin

•Type 2 DM: 2/3 of usual dose Insulin-exceptions: U500, 70/30

• Insulin pump

2017 UW Medicine Diabetic Pre Procedural Guidelines