perioperative management · lauruschkat20057310 cabg patients 5.2% dm. italian chapter ......

ITALIAN CHAPTER

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ITALIAN CHAPTERRoma, 7-10 novembre 2019

Pankaj Shah, MDEndocrinology

Mayo ClinicRochester, MN 55905

Perioperative Management

Pankaj Shah, [email protected]

Division of EndocrinologyMayo Clinic, Rochester, MN USA

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Speaker Disclosure

§ I, acting as chairman, speaker, tutor, teacher in the events organizedby Nord Est Congressi state that I have not had financial relationshipwith the any manufacturer(s) of healthcare product(s) or provider(s)of healthcare service(s) in the last two years.

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Objectives

• Should I be screening for diabetes preoperatively in patients who are at risk?

• When would I recommend postponing an elective surgical procedure because of poor diabetes control?

• When should I stop home diabetes medications?• How should I manage patients on insulin pumps in

the perioperative period?

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Undiagnosed DM in Surgical Patients

• Very high incidence of undiagnosed DM• Patients with undiagnosed DM have higher

morbidity and mortality than both non-diabetics and those with known diabetes

Study Patient population % DM or IFGAbdelmalak 2010 39,344 non-cardiac surgery 10% DM, 11% IFGSheehy 2012 Insured, elective surgery,

recent PCP visit24% DM or IFG

Lauruschkat 2005 7310 CABG patients 5.2% DM

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Effect of Intraoperative Glucose on Clinical Events

Gandhi et al Mayo Clin Proc 2005

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Intraoperative Glucose & Event Rates

after Gandhi et al Mayo Clin Proc 2005

0

10

20

30

40

50

60

70

80

<100 100-119 120-139 140-159 160-179 180-199 >200

%

Mean Glucose

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Pre-operative Screening for Diabetes Mellitus

• All patients above 45y if not screened recently• Known IFG or IGT• Patients below 45y if BMI >25 kg/m2 and

• Family h/o DM in first degree relative• High risk ethnicity• Cardiovascular disease, HTN, Dyslipidemia• PCOS, GDM or baby birth weight >4 kg• Physical inactivity• Severe obesity, acanthosis

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Objectives





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Elective surgery in patients with Diabetes: To proceed or not

• Postpone surgery if evidence of metabolic decompensation like Diabetic Ketoacidosis or Hyperglycemic Hyperosmolar State

• Severe hyperglycemia (? > 350 mg/dL) which would increase risk for metabolic decompensation

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Pre-operative Hemoglobin A1c

• No studies have examined benefit of delaying surgery to improve glucose control and outcomes

• Reasonable (but not necessary) to postpone elective surgery if HbA1c >8%, and obtain specialist consultation

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Objectives





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Managing Perioperative Hyperglycemia: Type 1 DM

• Never stop basal insulin• Never stop bolus insulin if patient is eating• Look out for hypoglycemia: Decrease basal insulin

(25-50%) if it appears to be excessive:• Nocturnal or early morning hypoglycemia• Overnight decline in blood sugars• Need for bedtime snack to avoid hypoglycemia• Skewed basal:bolus ratio

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Diabetes Medications Before Surgery

On the Day before surgery• No change except for possible reduction in long acting insulin at

night if there is concern for hypoglycemiaOn the Day of surgery• Oral medications and non-insulin injectables

• Do not take in the morning• Insulin therapy

• Basal: NPH – half dose; long acting – no change unless concern for hypoglycemia

• Bolus: Hold when NPO, resume with meals

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Simha and Shah, JAMA 2019

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Unaddressed Questions

• Metformin• SGLT-2 inhibitors

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Recent metformin in patients undergoing cardiac surgery

Variable Odds ratio and 95% CIMortality 0.5 (0.1, 2.0)Cardiac morbidity 0.3 (0.1, 1.7)Prolonged intubation 0.3 (0.1, 0.7)Renal morbidity 0.3 (0.1, 1.4)Neurologic morbidity 0.9 (0.3, 2.6)Infection morbidity 0.2 (0.1, 0.7)Overall morbidity 0.4 (0.2, 0.8)

Duncan Anesth Analg 2007;104:42-50No increased risk of adverse events?? Possible beneficial effects

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Glycosuria(urinary loss of glucose)

Natriuretic(urinary loss of sodium)

SGLT-2 inhibitors (‘gliflozins)canagliflozin (Invokana®), dapagliflozin (Farxiga®), empagliflozin

(Jardiance®), ertugliflozin (Steglatro®); Ipragliflozin (Suglat®); Tofogliflozin (Apleway®, Deberza®)

Hyperkalemic(increases serum potassium)

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Ketoacidosis with SGLT-2 Inhibitors

• Over 180 days follow up• Risk 2.2 (1.4–3.6)

• If not on insulin 2.5 (1.1–5.5)

Fralick et al NEJM 2017Peters et al Diab Care 2015

Taylor et al J Clin Endocrinol Metab. 2015

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Fadini et al. Diabetologia. 2017

0

1000

500

150020

14 Q

120

14 Q

220

14 Q

320

14 Q

420

15 Q

120

15 Q

220

15 Q

320

15 Q

420

16 Q

120

16 Q

220

16 Q

3

Type 2 DM

Type 1 DMOther DM

Total

Num

ber o

f rep

orts

SGLT-2 Inhibitor AssociatedDiabetic Ketoacidosis

2500

2000

Unknown Type of DM

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Sloan et al Endocrinol Diabetes Metab Case Rep. 2018

Bloo

d gl

ucos

e (m

g/dL

)

03672

108144180216

Day 1 Day 2 Day 3 Day 4 Day 5

Beta-hydroxybutyrate (mm

ol/L)

0123456

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Kelmenson et al. J Investig Med High Impact Case Rep. 2017

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SGLT-2 inhibitor in Type 1 diabetes?

Dapagliflozin (Farxiga®)• Dandona, et al (Depict 1) Lancet Diabetes Endocrinol. 2017• Mathieu, et al (Depict 1) Diabetes Care. 2018

Sotagliflozin (? Zynquista®): SGLT1 & SGLT2 inhibitor• Garg, et al (inTandem 3) NEJM 2017• Danne, et al (inTandem 2) Diab Care 2018• Buse, et al (inTandem 1) Diab Care 2017

Empagliflozin (Jardiance®)• Shimada et al Diabetes Obes Metab. 2018• Famulla et al (EASE1) Diabetes Technol Ther. 2017

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SGLT-2 Inhibitors and Type 1 Diabetes

Trial no. SotagliflozinEvents/N (/100 pt-yr)

Placebo Events/N (/100 pt-yr)

Hazard ratio Adjusted risk diff^ /100 pt-yr

Number needed to harm /yr

309/310 35/1,049 (3.40)

1/526 (0.19)

17.57 (2.4, 128.2)

3.21 (2.04, 4.38)

31 (22.8, 49.0)

312 21/699 (6.00)

4/703 (1.11)

5.37 (1.84, 15.64)

4.89 (2.17, 7.60)

21 (13.2, 46.1)

^: Exposure-adjusted Mantel-Haenszel risk difference

Wolfsdorf & Ratner Diab Diab Care 2019

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SGLT-2 Inhibitors

SGLT-2 inhibitor associated Diabetic Ketoacidosis• Type 2 diabetes >> Type 1 diabetes• Often another stress: surgery/ vascular event/ infection• Effect of SGLT-2 inhibition lasts for >2-3 days

• Current Protocol: stop on the day of surgeryImplication:• Stop SGLT-2 inhibitor 3-7 days before surgery.• Definitely stop for 3-7 days in Type 1 diabetes!!

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Objectives





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ITALIAN CHAPTERRoma, 7-10 novembre 2019CSII (insulin pump) vs Insulin infusion

Corney J Diab Sci Technol 2012;6(5):1003-1012

Continuation of Basal RateConversion to Intravenous InfusionSuspension (intermittent bolus)

0

20

40

60

Perc

ent S

urgi

cal C

ases

BG <70 In Target(70-179)

BG 180-<249 BG ³250

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ITALIAN CHAPTERRoma, 7-10 novembre 2019Preparation for surgery in patients on Insulin pump

• Continue usual basal insulin• Subcutaneous Pump or IV Insulin

• Bolus insulin: diet resumed; IV bolus to correct• Appropriate for surgery <2 hours

• not if prolonged surgery, vascular compromise or pump insertion site close to operative field

• Continuous glucose monitoring systems & closed loop system not validated in perioperative phase

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Conclusions

• Screen: all above 45, also if <45 + risk factor(s).• Postpone if elective surgery: DKA/ HHS

• HbA1c >8%• Stop Meds: All non-insulin and bolus insulin;

• NPH insulin: half; basal insulin: usual if appropriate• SGLT-2 inhibitors stop 3-7 days before procedure

• OK to use pumps for procedures less than 2 hours.• If type 1 diabetes – ALWAYS provide basal insulin?

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[email protected]

Pankaj Shah, M.D.Endocrinology, Mayo Clinic,

Rochester MN 55905

perioperative management · lauruschkat20057310 cabg patients 5.2% dm. italian chapter ......

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