Preoperative Diabetes Evaluation in Vascular Surgery Patients

May 24, 2019

DISCLOSUREEdie Shen, MD

• No relevant financial relationship reported

3

Diabetes and Vascular Disease

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

Perioperative Glucose Management

4

5

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

6

7

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

9

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

10

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

11

Low Carb Diet Pyramid

12

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

13

153

253

0

65

130

195

260

325

DOS fasting glucose

14

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