Perioperative Management of the Patient with Endocrine Disease: A Focus on Diabetes & Thyroid Dysfunction

Transcription

1 Perioperative Management of the Patient with Endocrine Disease: A Focus on Diabetes & Thyroid Dysfunction Luigi Meneghini, MD, MBA Professor, Internal Medicine (Endocrinology), UT Southwestern Medical Center Executive Director, Global Diabetes Program, Parkland Health & Hospital System

2 Advisory Board: Novo Nordisk, Sanofi, Intarcia Consultant: Sanofi Dyaeli Kunkel wife, mother of my children & rock of my life

3 Perioperative Diabetes Management

4 Increased mortality with increasing mean BG after CABG (coronary artery bypass) Mortality % Post-CABG Cardiac-related mortality Noncardiac-related mortality 2 0 < > 250 Average Postoperative Glucose (mg/dl) Furnary et al. J Thorac Cardiovasc Surg. 2003;125:

5 Lower mortality after CABG using IV 10 insulin for BG control Mortality (%) IV Insulin Protocol Patients with diabetes Patients without diabetes Year Furnary AP et al. J Thorac Cardiovasc Surg. 2003;125:

6 More complication in patients with diabetes after non-cardiac surgery 14% Diabetes Non-DM 12% 10% 8% 6% 4% 2% 0% Death Pneumonia* Wound * P < 0.05 infection* Sepsis/bact* UTI* AMI* ARF* Frisch, et al. Diabetes Care 2010; 33:

7 Recommendations regarding pre-operative A1C and peri-operative glycemic control

8 A1C > 8% associated with increased hospital LOS independent of perioperative glucose Hospital LOS (days) 30-d mortality (%) Wound infection (%) Controls 6.5% % % > 10% Pre-op A1C levels of patients with diabetes Only 1/3 of patients had an A1C w/in 90 days of surgery Underwood P, et al. Diabetes Care 2014;37:

9 Perioperative glycemic control, but not A1C predicts 30-day mortality post-op Non-cardiac surgery (n=6684) Cardiac surgery (6393) Mean perioperative glucose (mg/dl Mean perioperative glucose (mg/dl Preoperative A1C was good predictor of perioperative glycemic control Van den Boom, et al. Diabetes Care Feb 13. pii: dc doi: /dc [Epub ahead of print]

10 What A1C level is acceptable for elective surgeries? < 8.5% if it is safe to do so

11 Perioperative target blood glucose should be mg/dl up to 216 mg/dl acceptable mg/dl mg/dl < 180 mg/dl Beyond avoidance of marked hyperglycemia and hypoglycemia, the optimal perioperative glucose targets are unclear Dhatariya, et al. Diabetic Medicine 2012; 29: ADA Standards. Diabetes Care 2017; 40: S1-S136

12 Which diabetic therapies should you omit the day of surgery?

13 Outpatient pre-operative glycemic management: patient instructions Hold oral anti-diabetic agents the morning of surgery Hold non-insulin injectables the morning of surgery Hold rapid-acting (prandial) insulin the morning of surgery Adjust the basal insulin

14 Physiologic Insulin Replacement

15 Concept of basal bolus insulin Rx 325 BID options NPH Levemir QD options Glargine U100 Degludec Glargine U300 Regular Aspart/Lispro/Glulisine Faster-acting aspart Regular Aspart/Lispro/Glulisine Faster-acting aspart

16 Physiologic insulin secretion & replacement Basal Mealtime Corrective

17 Parkland perioperative insulin management protocol: initial prescription Total Daily Dose (TDD) 0.5 or 0.3 u/kg/day Take into account age, weight & renal function Total BASAL dose 50% of TDD Total PRANDIAL dose 50% of TDD NPH or Detemir twice daily Glargine or Degludeconce daily Distribute with meals Regular, Aspart, Lispro, Glulisine 3 times daily 56 y/o T2D Weight 96kg egfr > 60 cc/min TDD 0.5 u/kg/d x 96kg 48 units Basal 50% of units daily Prandial 50% of 48 3 meals 8 units QAC Odedosu K, et al. Submitted for presentation at ADA 2018

18 Basal insulin adjustments pre-operatively Night/evening before surgery Morning/day of surgery Intermediate-acting (NPH) Long-acting (Glargine, Detemir, Degludec) Premix (70/30, 75/25) 20% 50% 20% 50% Society of Hospital Medicine. 2015

19 What criteria should you use for using IV (intravenous) insulin versus SQ (subcutaneous) insulin perioperatively?

20 Intra-operative insulin management: IV or SQ? Duration of surgery Complexity of surgery: CABG, organ transplant, prolonged neurosurgical

21 Perioperative and intraoperative blood glucose monitoring Subcutaneous Intravenous Parkland Intraoperative insulin protocol Q 2-4 hours Q 1-2 hours Use rapid-acting analog for correction Use Regular insulin for correction

22 Transitioning to post-op glycemic management Subcutaneous Intravenous 325

23 Parkland perioperative insulin protocol Global Diabetes Program Perioperative Insulin Management Protocol Quality Improvement Initiative with Hospitalist U Team (Limb Salvage Team) Inpatient Podiatry Service HOSPITAL MEDICINE SURGERY ANESTHESIA PHARMACY NURSING INFORMATION TECHNOLOGY

24 Perioperative management of thyroid dysfunction

25 Perioperative complications of thyroid dysfunction Hypothyroidism Hypotension under anesthesia Ventilatory dysfunction Fluid & electrolyte disturbances Decreased clearance of anesthetics, tranquilizers & narcotics Post-operative ileus Anemia Myxedema coma Hyperthyroidism Cardiac arrhythmias Fever Gastrointestinal disturbances Thyroid storm High output heart failure Mental status changes

26 Preoperative screening for thyroid dysfunction Routine screening is not recommended However, if there is suspicion of thyroid dysfunction because of Symptoms Unexplained weight changes Palpitations Tremors Changes in bowel habits, skin or hair Skin abnormalities TSH Physical exam Exophthalmos Goiter Abnormal reflexes Hair/skin abnormalities Tachycardia or bradycardia

27 Diagnosis of HYPOthyroidism Central hypothyroidism TSH = serum free T4 Primary hypothyroidism (95% of cases) serum free T4 = TSH

28 Preparing the HYPOthyroid patient for surgery Pre-op Immediate pre-op Post-op Normalize TSH Continue LT4 LT4 1.6 mcg/kg/day (Elderly or CAD start 25 mcg/d) If NPO 5d, consider IV LT4 (Use 60-80% of oral dose) Severe hypothyroidism requiring urgent surgery Loading dose IV LT mcg + Consider stress dose CCS Dexamethasone 4mg IV bolus Daily dose IV LT mcg Bennet-Guerrero et al. Anesth Analg 1997; 85: Stahatos et al. Endocrinol Metab Clin North Am 2003; 32:

29 Diagnosis of HYPERthyroidism Central hyperthyroidism (rare) TSH = serum free T4 Primary hyperthyroidism serum free T4 = TSH

30 Preparing the HYPERthyroid patient for surgery Pre-op Immediate pre-op Post-op Overt disease Normalize TSH Mild/subclinical Beta-blockers Continue Thionamides If NPO may administer rectally Thionamides 3-8 weeks Beta-blockers Potassium iodide for Graves Severe hyperthyroidism requiring urgent surgery Intravascular hemodynamic monitoring Thionamides + beta-blockade Inorganic iodide Glucocorticoid Cholestyramine Glucocorticoid taper Thionamides = methimazole or propylthiouracil Ross, et al. Thyroid 2016 Oct;26(10):

31 Indications for surgical treatment of toxic goiter Parathyroid Adenoma Large thyroid size ( 80 g) Upper airway obstruction or dysphagia Graves ophthalmopathy Persistent hyperthyroidism following antithyroid meds & RAI Concomitant primary hyperparathyroidism Ross, et al. Thyroid 2016 Oct;26(10):

32 Preparing for removal of toxic goiter Pre-op Immediate pre-op Post-op Normalize TSH Thionamides 3-8 weeks Beta-blockers Potassium iodide for Graves Check &/or replete Calcium &/or 25-OH vit D Check calcium & ipth Stop thionamides Taper beta-blockers Replace LT4 Urgent surgery Intravascular hemodynamic monitoring Thionamides + beta-blockade Inorganic iodide Glucocorticoid Cholestyramine Glucocorticoid taper Thionamides = methimazole or propylthiouracil Ross, et al. Thyroid 2016 Oct;26(10):

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