PERIOPERATIVE DIABETES GUIDELINE

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1 PERIOPERATIVE DIABETES GUIDELINE This Guideline does not replace the need for the application of clinical judgment in respect to each individual patient. Background Diabetes mellitus is estimated to affect 7.4% of the Australian population, and is increasing annually by 0.8% (1). However, it is estimated that up to half of all cases remain undiagnosed (2). Approximately 10-15% of the surgical population is estimated to have a diagnosis of diabetes (3), and the rate of diabetes in all hospital patients is up to 25% in Australian audits (4). Patients with diabetes require surgical procedures more frequently, and have longer hospital stays than those without diabetes (5). The presence of diabetes or hyperglycaemia in surgical patients has been associated with up to 50% higher rates of morbidity and mortality (5). Poor perioperative glycaemic control is associated with worse surgical outcomes in cardiac and non-cardiac surgery. This includes increased incidence of post-operative respiratory infection, urinary tract infection, surgical site infection, myocardial infarction and acute kidney injury (5). There are many challenges to the perioperative glycaemic management of patients with Diabetes. These include, but are not limited to: fasting and bowel preparation, interruptions to usual therapy and the metabolic implications of stress and surgery. Most elective surgical patients are admitted on the day of surgery and will require instructions on perioperative management of their glycaemic control. This guideline aims to standardise care for patients with diabetes who are awaiting surgery. No guideline will be suitable for every patient. Please refer patient for Endocrinology review if more individualised treatment is required. The goals of perioperative glycaemic control are: 1. Target BGL range 5 10 mmol/l 2. Target HbA1c < 58 mmol/mol (7.5%) This guideline consists of 4 sections: 1. Flowchart for glycaemic management of surgical patients with diabetes seen in Perioperative Clinic 2. Perioperative management of Insulin therapy 3. Perioperative management of Oral Hypoglycaemic Agents and Non-insulin injectables 4. Patient management on day of surgery 5. Frequently asked questions

2 Assessment of glycaemic control in Perioperative clinic Pre-operative assessment of patient for elective surgery Assessment of glycaemic control: All Patients : Random BGL Diabetes : Random BGL, HbA1c in past 3 months or POC HbA1c, review blood glucose diary Diabetes control stable BGL 5-10 mmol/l HbA1c < 7.5% (58 mmol/mol) Diabetes control poor HbA1c > 7.5% (58 mmol/mol) 3 or more BGL mmol/l Severe hyperglycaemia BGL > 15 mmol/l New Hyperglycaemia HbA1c > 6.5% (48 mmol/mol) Random BGL > 10 mmol/l Proceed to surgery Advise management of diabetic medications in perioperative period Advise patients to check BGL on waking and 2 nd hourly Advise management of hypo or hyperglycaemia Consider requesting first on list as appropriate Optimise glucose control Consider referral to Emergency if patient clinically unwell Patient will require assessment and further management of diabetes. Consider - Referral to GP for outpatient management; or - Referral to patient s known Endocrinologist; or - Referral to Diabetes service at JHH. Contact Endocrine Advanced Trainee through switchboard for advice and outpatient appointments Major Surgery Consider deferring surgery if elective If surgery urgent discuss management and timing of surgery with Endocrine Advanced Trainee through switchboard Minor Surgery (Day only surgery) Consider proceeding to surgery if HbA1c < 8.5 %, surgery is minor and patient clinically stable. Optimise glycaemic control concurrently Repeat assessment of patient prior to surgery including assessment of glycaemic control

3 Insulin instructions Insulins (Examples) Day prior to admission Day of surgery ONCE DAILY Long acting (Morning) Lantus, Levemir, Toujeo Long acting (Evening) Lantus, Levemir, Toujeo TWICE DAILY Premixed insulins Humalog mix25 Humalog mix50 Novomix30 Mixtard 30/70 Mixtard 50/50 Humulin 30/70 Intermediate acting insulin Humulin NPH Protophane +/- short acting insulin Actrapid Novorapid Humulin R Humalog Apidra MULTIPLE DAILY INJECTIONS Basal bolus regimens Long acting insulin Lantus, Levemir, Toujeo Short acting insulins Actrapid Novorapid Humulin R Humalog Apidra Normal dose Continue at approx % dose No dose change No dose change No dose change Continue at approx % dose Continue at 100% dose Half usual morning dose Check BGL on waking and 2 hourly AM Surgery (fasting) Give 200mL of clear juice at time of insulin injection (but at least 2 hours pre-operatively) to avoid hypoglycaemia PM Surgery Early light breakfast with insulin at least six hours preoperatively Half usual morning dose of intermediate acting insulin only DO NOT give any rapid acting insulin Check BGL on waking and 2 hourly AM surgery (fasting) Give 200mL of clear juice at time of insulin injection (but at least 2 hours pre-operatively) to avoid hypoglycaemia PM Surgery Early light breakfast with insulin at least six hours preoperatively Check BGL on waking and 2 hourly AM surgery (fasting) Omit the morning and lunchtime short acting insulins Give basal insulin at % dose PM surgery Take morning basal and bolus insulin doses as normal with early light breakfast Omit lunchtime bolus dose INSULIN PUMP Insulin pump Seek guidance from Endocrine team and patient

4 Oral hypoglycaemic agents and non-insulin injectable instructions Oral hypoglycaemic agents Instructions Biguanides : Metformin ** (SEE BELOW) Sulfonylureas : Glibenclamide, Gliclazide Glimepiride, Glipizide DPP IV inhibitors : Alogliptin, Linagliptin, Saxagliptin, Sitagliptin, Vildagliptin Withhold on day of surgery Stop until eating and drinking as normal SGLT-2 inhibitors : Dapagliflozin, Empagliflozin, Canagliflozin Thiazolidinediones : Pioglitazone Alpha-glucosidase inhibitors : Acarbose Non-insulin injectable agents GLP-1 analogues : Exenatide, Liraglutide Instructions Withhold on day of surgery Stop until eating and drinking as normal Notes Metformin ** There is little evidence to support discontinuation of Metformin perioperatively, and some evidence that continuation is safe. However Metformin is renally excreted and renal failure may lead to high plasma levels which are associated with increased risk of lactic acidosis (3). A pragmatic approach is to discontinue in all patients on day of surgery, and for a further 48 hours in those patients if contrast media is to be used OR the egfr is < 60mL/min/1.73m2. Combination drugs These agents should be managed as per the individual agents. Pragmatically they should be ceased on day of surgery, and possibly for 48 hr post operatively if they contain metformin AND the patient has impaired renal function (egfr < 60mL/min/1.73m2) or contrast media is used. Risk of hypoglycaemia This occurs with agents that lower plasma glucose. This is predominantly the Sulfonylureas, SGLT-2 inhibitors and Acarbose. Other agents act by preventing glucose levels from rising and are a low risk of causing hypoglycaemia

5 PREOPERATIVE Review fasting status Check perioperative OHA and insulin management Give basal long-acting insulin if not already given by patient i.e Lantus or Levemir or Toujeo Measure and record BGL 2 hourly from 6am (by patient at home and then by Day stay staff) BGL 5-10 mmol/l Measure and record BGL 2 hourly proceed to Operating theatre BGL < 5 mmol/l Discuss with procedural Anaesthetist Patient can be given up to 200mL of clear juice up to 2 hours pre-operatively. Includes most juices, but not orange juice or other pulp juices Consider commencing IV 4% dextrose + one-fifth normal saline at mL/hr BGL < 5 mmol/l OR BGL > 10 mmol/l Consider bolus of 25-50mL of 50% dextrose if patient symptomatic or BGL < 4mmol/L. Give slowly over 1-3 minutes vein irritation may occur. Re-check BGL after 15 minutes if BGL < 4mmol/L Monitor BGL hourly BGL > 10 mmol/l Call RRT if patient unstable Discuss with procedural Anaesthetist Consider commencement of insulin infusion with protocol as per daily insulin dose (Use standard Adult Intravenous Insulin Infusion guideline) Monitor BGL hourly BGL > 15 mmol/l Discuss with procedural anaesthetist and consider discussion with Endocrinology team on call about further management of glycaemic control Consider measurement of capillary ketones in Type I diabetes mellitus Monitor BGL hourly POSTOPERATIVE General guidelines Patients should return to usual insulin regimen when consuming oral fluids and food or as instructed BGL should be recorded immediately after procedure, 2 hours, 4 hours, and then 4 hourly while in hospital Notify anaesthetist and/or medical team if BGL < 5 mmol/l or > 10 mmol/l After major surgery, in the post-surgical phase while fasting, the patient should have an insulin infusion using Adult Intravenous Insulin Infusion guideline commenced by anaesthetist. Consider referral to Endocrinology team for ongoing post-operative diabetes management

6 FREQUENTLY ASKED QUESTIONS 1. How is the diagnosis of Diabetes made? What is the role of HbA1c in the diagnosis of Diabetes? The diagnosis of Diabetes Mellitus has medical and legal implications for the patient and their family. There are strengths and limitations of the various approaches to diagnosis of diabetes. The criteria for the diagnosis of diabetes are now: HbA1c 6.5% (48 mmol/mol) Fasting glucose 7.0 mmol/l Random glucose 11.1 mmol/l On a 75 g oral glucose tolerance test: fasting glucose 7.0 mmol/l or 2 hr glucose 11.1 mmol/l If the HbA1c is elevated in an asymptomatic patient the test should be repeated for confirmation of the result and diagnosis. An abnormal result on 2 different diagnostic tests is also acceptable for the diagnosis of Diabetes. It is recommended that referral to Endocrinology outpatients be made before labeling a patient with a diagnosis due to the potential ramifications. 2. Why do we stop all oral hypoglycaemic agents perioperatively? Oral Hypoglycaemic agents (OHG) and the Non-insulin injectable agents act a subcellular level and stopping these agents on the day of surgery does not reverse the cellular changes that allow the drug to have an effect. However some agents do have potential adverse effects. The recently released AAGBI guidelines suggested continuation of all OHG and noninsulin injectable agents on the day of surgery, with the exception of Sulfonylureas and SGLT-2 inhibitors, due to hypoglycaemia and ketoacidosis respectively. It also recommended the continuation of Metformin except if the surgery involves the use of contrast or the patient s egfr is < 60mL/kg/1.73m2. However given the potential for confusion, a pragmatic approach is to withhold all OHG and non-injectable insulin medications on day of surgery. 3. What is a light breakfast? What fluids are appropriate with insulin administration? An example of a light breakfast includes toast and a clear fluid, or breakfast cereal and milk. It excludes fried and fatty food, as these may prolong gastric emptying time. The appropriate fluid to be administered with insulin includes carbohydrate to avoid hypoglycaemia. This includes : apple juice, other pulp-free fruit juice, cordial, lemonade, black tea and coffee. Other alternatives include commercial rehydration fluids, and commercial fat-free, protein-free high-energy nutritional supplements. 4. When patient s are prescribed an insulin infusion post operatively, what should we do with their Diabetes medication? OHGs and non-injectable insulins should be discontinued until patients are eating and drinking. Long acting insulins (Levemir and Lantus) should be continued while patients are on an insulin infusion. This provides basal insulin requirements and allows an easier transition to previous insulin regime. Intermediate acting insulin and short acting insulin should be discontinued until patient is eating and drinking. Generally insulin infusions are ceased after the recommencement of prior insulins.

7 REFERENCES 1. Australian Diabetes Society. Guidelines for routine glucose control in hospital nhospitalfinal2012_000.pdf 2. Valentine NA, Alhawassi TM, Roberts GW, Vora PP, Stranks SN, Doogue MP. Detecting undiagnosed diabetes using glycated haemoglobin: an automated screening test in hospitalised patients. Med J Aust. 2011;194(4): Association of Anesthetists of Great Britain and Ireland (2015) Guideline : Perioperative Management of the surgical patient with Diabetes 2015 : 4. Zhang A. Perioperative glycaemic control in diabetic surgical patients review. Australian Medical Students Journal (2): Frisch A, Chandra P, Smiley D, et al. Prevalence and clinical outcome of hyperglycemia in the perioperative period in non-cardiac surgery. Diabetes Care 2010; 33: New South Wales Agency for Clinical Innovation (2016). Perioperative Fasting in NSW Public Hospitals. data/assets/pdf_file/0006/299301/aci_key_princ iples_preoperative_fasting_in_nsw_public_hospitals.pdf Useful Links 1. Australian Diabetes Society (2012) Perioperative Diabetes Management Guideline : nesfinalcleanjuly2012.pdf 2. Association of Anesthetists of Great Britain and Ireland (2015) Guideline : Perioperative Management of the surgical patient with Diabetes 2015 : 3. Joint British Diabetes Societies for Inpatient Care (2015) Management of adults with diabetes undergoing surgery and elective procedures : Improving standards. Surgical%20guidelines%202015%20-%20full%20FINAL.pdf

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