Pre admission & surgery Pre-admission Nurses Association SIG Catherine Prochilo Credentialled Diabetes Nurse Educator Sat 23 March 2013

Transcription

1 Pre admission & surgery Pre-admission Nurses Association SIG Catherine Prochilo Credentialled Diabetes Nurse Educator Sat 23 March

2 Plan/ overview Issue/ presenting problems for people with diabetes in peri operative period Difference between major and minor surgery General principles of peri operative diabetes management Importance of maintaining BGLs within recommended range and targets for therapy Importance of pre operative screening Overview of insulin secretion in non diabetic state Common insulins used Use of insulin glucose infusion in peri op diabetes management Metformin, insulin pump and sliding scale recommendations

3 Issues/ presenting problems People with diabetes: Are more likely to need hosp admission (not for diabetes) and are more likely to have surgery or procedures than can disrupt glycaemic control Have a higher incidence of morbidity and mortality following surgery (Perioperative Diabetes Management Guidelines 2012)

4 Possible issues during periop period Hyperglycaemia due to: Increased counter regulatory (stress) hormones Insufficient insulin/ antihyperglycaemic medications Hypoglycaemia due to: Fasting Too much insulin/ antihyperglycaemic medications

5 Possible issues during periop period Diabetic ketoacidosis (DKA) generally in type 1 diabetes Due to total or relative insulin deficiency Dehydration Due to hyperglycaemia and insufficient fluid intake Electrolyte disturbance Due to dehydration, hyperglycaemia and certain medications

6 Perioperative guidelines Peri operative Diabetes Management Guidelines developed in July 2012 by Australian Diabetes Society (ADS) Largely not evidence based because evidence is lacking, rather represent consensus of opinions of working group of diabetes specialists

7 Major and minor surgery Peri op management may differ depending on whether it is minor or major surgery Minor surgery is defined as all day-only procedures, while major surgery includes all procedures that require at least an overnight admission Australian Diabetes Management Guidelines July 2012 (p.8)

8 General principles Diabetes should be well controlled prior to surgery (as evidenced by HbA1c within range, home BGLs stable and within range and nil or few hypos) Avoid insulin deficiency, and anticipate increased insulin requirements Patient should be well hydrated and ideally on the morning list The patient s diabetes care provider should be involved prior to surgery in the pre and post op management of their patients diabetes (including medication adjustment) Perioperative Diabetes Management Guidelines 2012

9 General principles Patients must be given clear written instructions concerning the management of their diabetes both pre and post op prior to surgery including: which medications need to be continued or stopped prior to surgery any information in regards to fasting or bowel preps How often to monitor pre admission and post discharge Patient s must not drive themselves to the hospital on the day of the procedure Perioperative Diabetes Management Guidelines 2012

10 Targets for therapy Ideally, HbA1c of <8% or 64mmol/mol If possible, postpone elective surgery, if glycaemic control is poor (HbA1c 9.0% or 75mmol/mol) BGLs should be kept between 5-10mmol/L during periop Report BGL of < 4.0mmol/L or > 15.0mmol/L

11 Pre operative screening Aims to prevent complications and promote healing Ensure patient is capable of managing after discharge Be aware of other co-morbidities including diabetes complications Detect any issues and rectify prior to surgery eg. Poor HbA1c Ideally accomplish screening early to enable interventions to take place if necessary Recommendations relate to: Type of diabetes Current diabetes management Time and duration of surgery Type of surgery; major or minor Each hospital should have own protocols be clear about your hospital s protocols and procedures

12 Check list considerations pre admission and/or at admission Type and duration of diabetes Management/ treatment of diabetes Does the patient monitor and record their BGLs? Have BGLs been reviewed by DNE/ endocrinologist? If on insulin, name and doses of all insulins and method of administration eg. Pump, pen, syringe If taking antihyperglycaemic meds, are they MR (modified release) or IR (immediate release)? What is their HbA1c? Ie. Is the patient s diabetes well controlled? (pre admission) Are they having more than 2 hypos per week? Is the patient appropriate for your centre?

13 Frequency of BGL monitoring Patient should monitor (and record) more frequently 1-2 weeks prior to procedure Pre meals and pre bed On admission Hourly Prior to discharge Patient should monitor more often a few days after procedure Pre meals and pre bed

14 What patients need: Individualised written instructions in advance of procedure that are: Clear and unambiguous Simple to read (not medical jargon) Up to date and current They should provide the following information: Frequency of monitoring of BGLs (and of ketones as necessary) Reportable BGL parameters Hypoglycaemia management as necessary Adjustment of medications/ insulin

15 Overview of insulin secretion in the non diabetic state Basal insulin: Continuously secreted in small amounts to maintain cellular function - keeps person alive Keeps BGLs steady, independent of the amount of carbohydrate eaten over 24 hours Levels fluctuate depending on time of day, weight, exercise, illness and stress Bolus/prandial/mealtime insulin Additional bursts precisely matched to respond to carbohydrate intake Levels fluctuate depending on the amount of carbohydrate ingested, time of day, weight, exercise, illness and stress

16 Mimicking physiological release of insulin

17 Basal analogue insulins Lantus & Levemir last longer than the older isophane insulins and have less of a peak: Lantus: Onset time hrs Peak time nil distinct peak Duration hrs Levemir Onset time hrs Peak time nil distinct peak Duration up to 18

18 Practice points Lantus can last up to 24 hours, but often does not Levemir does not last 24 hrs most of the time (usually last up to 18 hrs) and needs to be given twice daily (evenly divided) to give 24 hour coverage Protaphane is usually given at night but if given twice daily (evenly divided) it works much like twice daily Levemir to give 24 hour coverage

19 Bolus/prandial/mealtime insulin analogues NovoRapid, Humalog and Apidra work much more quickly than the older insulins such as Actrapid or Humulin R: Onset time 5-15 mins rather mins Peak at hrs rather than hrs Lasts 4-5 hrs rather than 6-8 hrs Work more quickly to correct high blood glucose levels Do not last as long so less risk of hypos hrs after injection Match glucose rise in blood stream after carbohydrate intake more closely

20 2.5 Humalog NovoRapid Regular Insulin (Actrapid,Humulin R) Protaphane Humulin NPH 2.0 Lantus, Detemir Hours after 1 Injection Hours after injection 0 1 2

21 Practice point Assume that all patients treated with insulin are insulin deficient Therefore, all patients treated with insulin, whether type 1 or type 2 diabetes, should be managed in the same way Never omit basal insulin in these patients

22 Type 1 diabetes and ketosis Risk of ketone production which may lead to diabetic ketoacidosis (DKA) if: Basal insulin is withheld or Illness or infection results in insulin insufficiency* Ketone testing should be performed if BGL >15mmol/L, if patient is ill or unwell or as per doctor s request Some people with longstanding type 2 diabetes on insulin may be at risk of DKA NB: During times of stress or illness individuals may require higher doses of insulin

23 Insulin-glucose (I-G) infusion Best way to maintain euglycaemia and tight glycaemic control without causing hypoglycaemia during peri op period Each hospital should have own protocols Staff need to be trained appropriately

24 Guidelines when using an I-G infusion Insulin and glucose infused at the same time: Insulin infusion rate is titrated according to BGL in order to achieve BGLs between 5-10mmol/L, whilst glucose infusion rate is kept constant (except if BGL is elevated eg. 15mmol/L in which case glucose infusion should be delayed until BGL has improved)

25 Guidelines when using I-G infusion What occurs: Omit usual diabetes treatment on morning of surgery and commence infusion prior to 10am All require hourly (or 2 nd hrly at least) BGL monitoring Infusion can be ceased once patient has resumed diet and fluids, and, 1-2 hours after s/c insulin or antihyperglycaemic agents have been administered

26 Who could need an I-G infusion? Type 1 (whether on injections or insulin pump) or type 2 insulin treated (with or without antihyperglycaemics) diabetes: having major surgery having minor surgery and whose BGLs remain elevated >10mmol/L pre op, or who are on an afternoon list and have unstable BGLs pre op Type 2 on antihyperglycaemic agents (without insulin) having major surgery and BGLs >10mmol/L Patients with unstable BGLs during period of bowel prep (there are specific guidelines for bowel prep) NB: This does not include all patient scenarios (refer to ADS Peri Operative Diabetes Management Guidelines 2012)

27 Who does not need an I-G infusion? Type 2 diabetes diet controlled with HbA1c within range ie. HbA1c <6.5% Type 2 diabetes on antihyperglycaemic agents with BGLs <10mmol/L in pre op period Type 1 and type 2 insulin treated having minor surgery and surgery completed and tolerating food and fluids by 10am

28 Sulphonylureas Only class of drugs that can cause hypoglycaemia Some are modified release (MR) and work for 24 hrs, and others are immediate release and work from meal to meal In people with renal impairment they can cause prolonged and severe hypoglycaemia (especially Glibenclamide)

29 Metformin recommendations Major surgery: stop on day of surgery and recommence if serum creatinine level does not deteriorate post operatively Minor surgery: need not be stopped Bowel prep: stop from the day of clear fluids until after procedure Intravenous Radio-contrast: stop 24 hours prior, check creatinine to asess renal function, wait 48 hours after procedure and recheck serum creatinine

30 Insulin Pumps Can be used for minor procedures but are not appropriate for major surgery Patient to continue with usual basal rate Pump should not be worn during X ray, CT or MRI scan

31 SLIDING SCALE INSULIN Subcutaneous insulin sliding scales are NOT recommended for post op management of diabetes when used as sole form of insulin coverage Sliding scales are aimed at correcting rather than preventing hyperglycaemia When used as sole therapy they can lead to inadequate and inappropriate insulin administration and often result in large swings in BGLs They are often forgotten and not reviewed or adjusted regularly

32 Summary Foreward planning and preparation is the key to improving outcomes Improve glycaemic control pre op (reviewed by diabetes team) - prevention of hyperglycaemia reduces risk of adverse outcomes Ensure patient has had clear instructions for fasting for surgical procedure, what medication to omit, continue or adjust, and recommence post op Know exactly what patient you have in front of you i.e. type 1 or 2, diet controlled, OHAs or on insulin Ideally diabetes review by DNE whilst in patient

33 References Australian Diabetes Society, Peri- operative diabetes management guidelines 2012 Australian Diabetes Society, Guidelines for Routine Glucose control in Hospital 2012 Hospital stay, day surgery & procedures information sheet proce dures_2011.pdf diabetes_2012.pdf diabetes_2012. pdf

34 570 Elizabeth Street Melbourne Victoria 3000 t f info line e mail@diabetesvic.org.au w ABN