diabetes and the surgical patient dr. cathy code october 14, 2008

Diabetes and the Diabetes and the Surgical PatientSurgical Patient

Dr. Cathy CodeDr. Cathy Code

October 14, 2008October 14, 2008

ObjectivesObjectives

►Review the various agents used to treat Review the various agents used to treat diabetesdiabetes

►Discuss the impact of surgery on diabetesDiscuss the impact of surgery on diabetes►Provide a framework for the preoperative Provide a framework for the preoperative

assessment of a diabetic patientassessment of a diabetic patient►Provide a practical approach to the Provide a practical approach to the

perioperative management of diabetes perioperative management of diabetes

DiabetesDiabetes

►Common chronic disorderCommon chronic disorder►Associated with both macrovascular Associated with both macrovascular

and microvascular complicationsand microvascular complications►More surgical interventionsMore surgical interventions►A diabetic has a 50% chance of A diabetic has a 50% chance of

requiring a surgery in their lifetimerequiring a surgery in their lifetime►20% of surgical patients have diabetes20% of surgical patients have diabetes

DiabetesDiabetes

►Complex interaction b/w operative Complex interaction b/w operative procedure, type of anesthesia, and procedure, type of anesthesia, and postoperative factorspostoperative factors

►Diabetic patient requires careful Diabetic patient requires careful assessment prior to surgeryassessment prior to surgery

► Increased length of hospital stay and Increased length of hospital stay and cost cost

► Increased risk of periop infection and Increased risk of periop infection and postop CVS morbidity and mortalitypostop CVS morbidity and mortality

Type 1 DMType 1 DM

►Primarily a result of pancreatic beta Primarily a result of pancreatic beta cell destructioncell destruction

►Absolute insulin deficiencyAbsolute insulin deficiency►Prone to ketoacidosisProne to ketoacidosis►Autoimmune process vs idiopathicAutoimmune process vs idiopathic►Requires ongoing insulin treatmentRequires ongoing insulin treatment

Type 2 DMType 2 DM

►Predominant abnormality is insulin Predominant abnormality is insulin resistanceresistance

►May be treated with diet, OHG and or May be treated with diet, OHG and or insulininsulin

►Others:Others: Diseases of pancreasDiseases of pancreas EndocrinopathiesEndocrinopathies DrugsDrugs

Oral HypoglycemicsOral Hypoglycemics►AcarboseAcarbose

Alpha-glucosidase inhibitorAlpha-glucosidase inhibitor

►SulfonylureasSulfonylureas Insulin secretagoguesInsulin secretagogues ex. Glyburide (Diabeta), Gliclazide ex. Glyburide (Diabeta), Gliclazide

(Diamicron)(Diamicron) Rapid BG lowering potentialRapid BG lowering potential

►MeglitinidesMeglitinides Insulin secretagoguesInsulin secretagogues ex. Repaglinide (GlucoNorm)ex. Repaglinide (GlucoNorm)

Oral HypoglycemicsOral Hypoglycemics

►MetforminMetformin Negligible hypoglycemic riskNegligible hypoglycemic risk CI in renal failure (GFR < 30ml/min) and CI in renal failure (GFR < 30ml/min) and

hepatic failurehepatic failure

►TZDsTZDs ex. Pioglitazone (Actos), Rosiglitizone ex. Pioglitazone (Actos), Rosiglitizone

(Avandia)(Avandia) Avoid in CHFAvoid in CHF ? Association with increased ? Association with increased

cardiovascular eventscardiovascular events

Insulin TypeInsulin Type OnsetOnset PeakPeak DurationDuration

Prandial InsulinsPrandial Insulins

Rapid–actingRapid–acting►Aspart Aspart (Novorapid)(Novorapid)►Lispro (Humalog)Lispro (Humalog)

10-15 mins10-15 mins

10-15 mins10-15 mins1-1.5 hrs1-1.5 hrs

1-2 hrs1-2 hrs3-5 hrs3-5 hrs

3.5-4.5 hrs3.5-4.5 hrs

Short-actingShort-acting►Humulin RHumulin R►Novolin TorontoNovolin Toronto

30 mins30 mins 2-3 hrs2-3 hrs 6.5 hrs6.5 hrs

Basal InsulinsBasal Insulins

Intermediate-Intermediate-actingacting►Humulin NHumulin N►Novolin NPHNovolin NPH

1-3 hrs1-3 hrs 5-8 hrs5-8 hrs Up to 18 hrsUp to 18 hrs

Long-actingLong-acting►Detemir Detemir (Levemir)(Levemir)►Glargin (Lantus)Glargin (Lantus)

90 mins90 mins n/an/a Up to 24 hrsUp to 24 hrs

Preoperative AssessmentPreoperative Assessment::►Focus on cardiopulmonary risk Focus on cardiopulmonary risk

assessment and modificationassessment and modification►CHD more common in diabeticsCHD more common in diabetics►Associated conditions:Associated conditions:

HTNHTN ObesityObesity CKDCKD Cerebrovascular diseaseCerebrovascular disease Autonomic neuropathyAutonomic neuropathy

Preoperative AssessmentPreoperative Assessment::

►Key elements:Key elements: Type of DMType of DM Longterm complicationsLongterm complications Baseline glycemic controlBaseline glycemic control Assessment of hypoglycemiaAssessment of hypoglycemia Diabetic medsDiabetic meds Other medsOther meds Characteristics of surgeryCharacteristics of surgery Type of anestheticType of anesthetic

Preoperative TestingPreoperative Testing::

►Baseline ECGBaseline ECG►Renal FunctionRenal Function►Hgb A1CHgb A1C

Determination of chronic glycemic controlDetermination of chronic glycemic control Elevated levels may predict a higher rate Elevated levels may predict a higher rate

of postop infectionsof postop infections

►Noninvasive cardiac testing if Noninvasive cardiac testing if indicatedindicated

Impact of SurgeryImpact of Surgery

►Surgery and anesthesia lead to a Surgery and anesthesia lead to a neuroendocrine stress responseneuroendocrine stress response

►Counterregulatory hormones:Counterregulatory hormones: EpinephrineEpinephrine GlucagonGlucagon CortisolCortisol Growth HormoneGrowth Hormone Inflammatory cytokinesInflammatory cytokines


►Leads to:Leads to: Insulin resistanceInsulin resistance Decreased peripheral glucose utilizationDecreased peripheral glucose utilization Impaired Insulin secretionImpaired Insulin secretion Increased lipolysisIncreased lipolysis Protein catabolismProtein catabolism

►Hyperglycemia and possibly ketosisHyperglycemia and possibly ketosis


►Varies per individualVaries per individual► Influenced by type of anesthesiaInfluenced by type of anesthesia

GA > spinal anesthesia GA > spinal anesthesia

►Extent of surgeryExtent of surgery Major vs minorMajor vs minor

►Postoperative factorsPostoperative factors Sepsis, hyperalimentation, steroid useSepsis, hyperalimentation, steroid use

GoalsGoals

►Maintenance of fluid and electrolyte Maintenance of fluid and electrolyte balancebalance uncontrolled DM leads to volume uncontrolled DM leads to volume

depletion from osmotic diuresisdepletion from osmotic diuresis

►Prevention of ketoacidosisPrevention of ketoacidosis Type 1 diabetics are insulin deficient and Type 1 diabetics are insulin deficient and

require continuous insulin administrationrequire continuous insulin administration

GoalsGoals

►Avoidance of marked hyperglycemiaAvoidance of marked hyperglycemia DKA in Type 1 diabeticsDKA in Type 1 diabetics Nonketotic hyperosmolar state in Type 2 Nonketotic hyperosmolar state in Type 2

diabeticsdiabetics

►Avoidance of hypoglycemiaAvoidance of hypoglycemia Potentially a life threatening complicationPotentially a life threatening complication Cardiac arrhythmiasCardiac arrhythmias Cognitive deficits and neurologic sequelaeCognitive deficits and neurologic sequelae

Glycemic TargetsGlycemic Targets

►Exact target unclearExact target unclear►Limited evidence and lack of controlled Limited evidence and lack of controlled

trials except….trials except…. Coronary bypass surgery, IV insulin to Coronary bypass surgery, IV insulin to

maintain BS 5.5-10.0, associated with less maintain BS 5.5-10.0, associated with less sternal wound infection and mortalitysternal wound infection and mortality

Surgical ICU patients with hyperglycemia, Surgical ICU patients with hyperglycemia, IV insulin to maintain BS 4.5 – 6.0, reduced IV insulin to maintain BS 4.5 – 6.0, reduced mortality and morbiditymortality and morbidity


►Meta-analysis of RCTs in JAMA 2008Meta-analysis of RCTs in JAMA 2008 29 RCTs of tight glycemic control in 29 RCTs of tight glycemic control in

critically ill patients in an ICU settingcritically ill patients in an ICU setting No evidence of improved patient oriented No evidence of improved patient oriented

outcomesoutcomes Found increased frequency in potentially Found increased frequency in potentially

harmful hypoglycemia in patients treated harmful hypoglycemia in patients treated with glucose controlwith glucose control


►Otherwise……Otherwise……►Published guidelines collectively Published guidelines collectively

propose attempting to achieve propose attempting to achieve reasonable normoglycemiareasonable normoglycemia

►2008 CDA guidelines:2008 CDA guidelines: Perioperative glycemic levels should be Perioperative glycemic levels should be

maintained between 5.0 – 11.0maintained between 5.0 – 11.0 avoid hypoglycemiaavoid hypoglycemia Grade D, consensusGrade D, consensus

Diabetes ManagementDiabetes Management::Early perioperative phaseEarly perioperative phase

►Several various strategiesSeveral various strategies►No consensus on optimal therapyNo consensus on optimal therapy►Aim to have surgery early in am to Aim to have surgery early in am to

minimize disruption of their minimize disruption of their management while NPOmanagement while NPO


►T2DM, diet aloneT2DM, diet alone:: Usually do not require any therapy periopUsually do not require any therapy periop Supplemental short acting insulin Supplemental short acting insulin

(regular, humalog, novorapid) may be (regular, humalog, novorapid) may be given by sliding scale if levels above given by sliding scale if levels above targettarget

Check BS preop and postopCheck BS preop and postop IV dextrose not required unless insulin is IV dextrose not required unless insulin is

administered and patient NPOadministered and patient NPO


►T2DM on OHGT2DM on OHG:: Hold OHG am of ORHold OHG am of OR Most patients with good control will not Most patients with good control will not

require insulin for short surgical proceduresrequire insulin for short surgical procedures Short-acting supplemental insulin by sliding Short-acting supplemental insulin by sliding

scale can be used for hyperglycemiascale can be used for hyperglycemia Restart OHG when patients resume eatingRestart OHG when patients resume eating Hold metformin is patient has developed Hold metformin is patient has developed

renal impairmentrenal impairment


►Type 1 DM or insulin treated Type Type 1 DM or insulin treated Type 2 DM2 DM:: For short, non complex procedures For short, non complex procedures

patients can usually continue SC insulinpatients can usually continue SC insulin Continue long-acting insulin while NPO Continue long-acting insulin while NPO

and on IV dextroseand on IV dextrose For patients with tight control or prone to For patients with tight control or prone to

hypoglycemia, reduce evening/hs insulin hypoglycemia, reduce evening/hs insulin night before surgery night before surgery

Diabetes ManagementDiabetes Management::Timing of ProcedureTiming of Procedure

►Minor, early morning procedures, Minor, early morning procedures, breakfast only delayedbreakfast only delayed patients can take their insulin after surgerypatients can take their insulin after surgery

► Procedures where breakfast and lunch Procedures where breakfast and lunch missedmissed Omit short-acting insulin and give 1/2 to 2/3 of Omit short-acting insulin and give 1/2 to 2/3 of

long-acting insulin long-acting insulin OROR Take 1/3 to 1/2 of total morning dose as long-Take 1/3 to 1/2 of total morning dose as long-

acting only acting only OROR SC insulin pump, continue basal rate SC insulin pump, continue basal rate OROR Start dextrose containing IV solutionStart dextrose containing IV solution

Diabetes ManagementDiabetes Management::Timing of ProcedureTiming of Procedure►Long and complex proceduresLong and complex procedures

IV insulin is required for Type 1 diabetics IV insulin is required for Type 1 diabetics and Insulin requiring Type 2 diabeticsand Insulin requiring Type 2 diabetics

SafeSafe Easily titrated with a short ½ life (5 – 10 Easily titrated with a short ½ life (5 – 10

minutes)minutes) Usually started morning prior to surgeryUsually started morning prior to surgery IV insulin infusion algorithmsIV insulin infusion algorithms

Diabetes ManagementDiabetes Management::Late postoperative phaseLate postoperative phase

►Preoperative diabetes treatment can be Preoperative diabetes treatment can be reinstated once the patient is eating wellreinstated once the patient is eating well

►Metformin should not restart in renal Metformin should not restart in renal insuffinsuff

►Sulfonylureas should only be started after Sulfonylureas should only be started after patient eating well, consider stepwise patient eating well, consider stepwise approachapproach

►Avoid TZDs in CHF or problematic fluid Avoid TZDs in CHF or problematic fluid retentionretention

Diabetes ManagementDiabetes Management::Late postoperative phaseLate postoperative phase

► Insulin infusions should be continued Insulin infusions should be continued until solids well tolerated then switch until solids well tolerated then switch to SC insulinto SC insulin

►For patients on SC insulin, continue IV For patients on SC insulin, continue IV dextrose until patient eating welldextrose until patient eating well

Sliding ScalesSliding Scales

►Often used to correct elevated levelsOften used to correct elevated levels►Problematic if used as the sole method Problematic if used as the sole method

of diabetic treatmentof diabetic treatment►Reactive process, causes wide Reactive process, causes wide

fluctuation in serum glucosefluctuation in serum glucose►Should never be the sole method of Should never be the sole method of

treatment in T1DM due to risk of treatment in T1DM due to risk of ketosisketosis

Example - standardExample - standard► Regular, Humalog, Novorapid Insulin, TID, Regular, Humalog, Novorapid Insulin, TID,

ac mealsac meals

BS readingBS reading InsulinInsulin

0 – 4.00 – 4.0 No insulin, give sugarNo insulin, give sugar

4.1 – 8.04.1 – 8.0 No insulinNo insulin

8.1 – 11.08.1 – 11.0 2 units2 units

11.1 – 14.011.1 – 14.0 4 units4 units

14.1 – 16.014.1 – 16.0 6 units6 units

16.1 – 18.0 16.1 – 18.0 8 units8 units

18.1 – 20.018.1 – 20.0 10 units10 units

> or = 20.1> or = 20.1 Call MDCall MD

Example – Insulin sensitiveExample – Insulin sensitive► Elderly, lean patients or individuals with Elderly, lean patients or individuals with

renal or liver dysfunctionrenal or liver dysfunction





11.1 – 14.011.1 – 14.0 2 units2 units

14.1 – 16.014.1 – 16.0 3 units3 units

16.1 – 18.016.1 – 18.0 4 units4 units

18.1 – 20.018.1 – 20.0 5 units5 units


Example – Insulin resistantExample – Insulin resistant►Obesity, treatment with glucocorticoidsObesity, treatment with glucocorticoids




8.1 – 11.08.1 – 11.0 4 units4 units

11.1 – 14.011.1 – 14.0 8 units8 units

14.1 – 16.014.1 – 16.0 12 units12 units

16.1 – 18.016.1 – 18.0 16 units16 units

18.1 – 20.018.1 – 20.0 20 units20 units


Special ConsiderationsSpecial Considerations

►GlucocorticoidsGlucocorticoids Used to treat many disorders, given in Used to treat many disorders, given in

“stress” doses perioperatively“stress” doses perioperatively Can worsen existing DM and trigger Can worsen existing DM and trigger

hyperglycemia in othershyperglycemia in others Augment hepatic gluconeogenesis, inhibit Augment hepatic gluconeogenesis, inhibit

glucose uptake, and alter receptor functionglucose uptake, and alter receptor function 2 to 3 fold increase in total daily insulin can 2 to 3 fold increase in total daily insulin can

be required with stress dosesbe required with stress doses

Special ConsiderationsSpecial Considerations

►HyperalimentationHyperalimentation TPNTPN

►increase blood glucoseincrease blood glucose►Increase basal insulin, add insulin to TPNIncrease basal insulin, add insulin to TPN

NG feedsNG feeds►Either a IV insulin infusion or BID long-acting Either a IV insulin infusion or BID long-acting

insulin + sliding scaleinsulin + sliding scale►Make sure to change insulin if feeds changes Make sure to change insulin if feeds changes

to bolusto bolus

Case examplesCase examples►Case #1Case #1►Mr S, 58 yr old man with newly dx’d Mr S, 58 yr old man with newly dx’d

colorectal Ca colorectal Ca ►Scheduled for Right HemicolectomyScheduled for Right Hemicolectomy►Hx of T2DM maintained on metformin Hx of T2DM maintained on metformin

and Novolin NPH 16u SC qam and 10u and Novolin NPH 16u SC qam and 10u SC qpmSC qpm

►Hx of controlled HTN, stable anginaHx of controlled HTN, stable angina►How should this patient be managed? How should this patient be managed?

Case #1 cont….Case #1 cont….

►PreopPreop Bowel prep and NPO at midnightBowel prep and NPO at midnight Hold Metformin morning of ORHold Metformin morning of OR Give 8u of NPH insulin am of ORGive 8u of NPH insulin am of OR Provide IV dextrose during ORProvide IV dextrose during OR

►PostopPostop Hold metformin until eating wellHold metformin until eating well Give 16u of NPH qam and 10u of NPH qpmGive 16u of NPH qam and 10u of NPH qpm Continue IV dextrose until eating wellContinue IV dextrose until eating well Insulin sliding scale TID prn with mealsInsulin sliding scale TID prn with meals

Case examplesCase examples

►Case #2Case #2►Ms P, 36 yr old female with perforated Ms P, 36 yr old female with perforated

DU awaiting in ER for urgent ORDU awaiting in ER for urgent OR►Type 1 DM for 15 yrs complicated by Type 1 DM for 15 yrs complicated by

retinopathy, neuropathy, and retinopathy, neuropathy, and gastroparesisgastroparesis

►On Levemir 20u BID and Novorapid On Levemir 20u BID and Novorapid sliding scale with meals by carb sliding scale with meals by carb counting, average 4-6u per mealcounting, average 4-6u per meal

►How should this patient be managed?How should this patient be managed?

Case #2 cont..Case #2 cont..

►PreopPreop NPO, frequent glucoscansNPO, frequent glucoscans IV regular insulin starting at 2u/hrIV regular insulin starting at 2u/hr IV dextroseIV dextrose

►PostopPostop Continue IV insulin and dextrose until Continue IV insulin and dextrose until

eating well and overlap with SC insulineating well and overlap with SC insulin Watch for nausea and vomiting given hx Watch for nausea and vomiting given hx

of gastroparesisof gastroparesis

Take Home MessageTake Home Message

►Common chronic health problemCommon chronic health problem►Needs to be managed closely Needs to be managed closely

perioperativelyperioperatively►Associated with increased Associated with increased

perioperative riskperioperative risk►Not aiming for perfect glucose Not aiming for perfect glucose

measurements but instead safe measurements but instead safe measurementsmeasurements

diabetes and the surgical patient dr. cathy code october 14, 2008

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