Society for Ambulatory Anesthesia Consensus Statement on Perioperative Blood Glucose Management in Diabetic Patients Undergoing Ambulatory Surgery

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1 Society for Ambulatory Anesthesia Consensus Statement on Perioperative Blood Glucose Management in Diabetic Patients Undergoing Ambulatory Surgery Girish P. Joshi, MB BS, MD, FFARCSI Anesthesia & Analgesia 2010; 111: A systematic review of the literature was conducted according the protocol recommended by the Cochrane Collaboration. The consensus panel used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system for developing the consensus statement. It was revealed that the literature on perioperative glycemic control in patients undergoing ambulatory surgery is sparse and of limited quality. In absence of high quality evidence, recommendations were based on general principles of blood glucose control in diabetics, drug pharmacology, data from inpatient surgical population and clinical judgment. The consensus panel considered specific clinical questions. 1. Preoperative information specifically related to glycemic control should be obtained in the diabetic patient? Level of glycemic control (as assessed by blood glucose levels and HbA1c, if available). Type and of antidiabetic therapy (i.e., oral antidiabetics and/or insulin). Frequency and manifestations of hypoglycemia. Blood glucose level at which hypoglycemic symptoms occur. Hospital admissions due to glycemic control issues. Ability of the patient to reliably test their blood glucose levels. 2. How do we manage preoperative oral antidiabetic and non-insulin injectable therapy? Hypoglycemia does not occur in patients on oral antidiabetics except rarely with sulfonylureas, meglitinides, and non-insulin injectables. It may not be necessary to discontinue these drugs prior to the day of surgery; however, they should not be taken on the day of surgery. Lactic acidosis rarely occurs with metformin, thus, may not be necessary to discontinue it 48 h prior to surgery. 3. How do we manage preoperative insulin therapy? Insulin Regimen Day Before Surgery Day of Surgery Comments Insulin pump - Use sick day or sleep basal rates Long-acting, peakless Intermediateacting - in the daytime - 75% of if taken in the evening % of morning 50-75% of morning - Reduce nighttime if history of nocturnal or morning hypoglycemia - On the day of surgery, the morning of basal insulin may be administered on arrival to the ambulatory surgery facility - See the comments for longacting

2 Fixed combination 50-75% of morning of intermediate-acting component - Lispro-protamine only available in combination, therefore use NPH instead, on day of surgery - See the comments for longacting Short- and Rapid-acting insulin Hold the Non-insulin injectables Hold the 4. Is there a preoperative blood glucose level above which one should postpone elective surgery? Surgery should be postponed in patients with hyperglycemic crisis such as ketoacidosis and hyperosmolar non-ketotic states. It may be acceptable to proceed with surgery in patients with preoperative hyperglycemia, if they had adequate long-term glycemic control. In chronically poorly controlled diabetics, the decision to proceed with ambulatory surgery should be made in conjunction with the surgeon while taking into consideration the presence of other comorbidities and the potential risks of surgical complications. 5. What is the optimal intraoperative period blood glucose level? In patients with well-controlled diabetes, intraoperative blood glucose levels should be maintained less than 180 mg/dl (10 mmol/l). However, chronically elevated blood glucose levels should be maintained at the level at which they live. Also, do not acutely decrease the blood glucose levels. 6. How do we maintain optimal blood glucose levels? Subcutaneous administration of rapid-acting insulin analogs is the preferred method for achieving and maintaining target glucose levels. There is not enough evidence to recommend a dosing schedule to optimize the blood glucose levels. The rule of 1800 or 1500, which provides the expected decrease in blood glucose with each unit of insulin may be used. Thus, if the patients daily insulin requirement were 60 units, one unit of insulin would reduce in blood glucose level by mg (i.e., 1500/60 or 1800/60). 7. What are the other considerations specific to glycemic control in diabetic outpatients? Patients should travel with a suitable treatment for hypoglycemia that might occur in transit. Aggressive nausea and vomiting prophylaxis is recommended. Dexamethasone 4 mg can be used, but should be followed with appropriate monitoring of blood glucose levels. 8. What is the optimal perioperative blood glucose monitoring? Blood glucose levels should be checked on the patient s arrival to the facility as well as prior to discharge home. Intraoperative blood glucose monitoring can be performed every 1-2 hour, depending upon the duration of procedure and type of insulin used. For example, intraoperative monitoring may not be necessary for procedures less than 2 hours.

3 More frequent measurements may be required for patients who have received insulin and those with lower blood glucose levels. 9. How should we identify and manage perioperative hypoglycemia? Blood glucose level of less than 70 mg/dl is generally considered as an alert value for hypoglycemia. In the symptomatic patient, the preferred method for treatment of hypoglycemia is consumption of gm of glucose, which is repeated until blood glucose rises and symptoms resolve. Overzealous glucose administration should be avoided as hyperglycemia can have significant detrimental. 10. What are the discharge considerations for diabetic outpatients? Patients should be observed in an ambulatory facility until the possibility of hypoglycemia from perioperatively-administered insulin is ruled out. 11. What advice should we give to patients for glucose control after discharge home? Patients should be instructed to check blood glucose levels frequently while fasting. Patients should carry hypoglycemia treatments while traveling to and from the surgical facility. Patients should be advised that transition to daily preoperative antidiabetic regimens should be delayed if normal caloric intake is delayed.

4 Pharmacology of Oral Antidiabetic Agents Drug Class: Generic (Trade name) Biguanide Metformin (Glucophage) Metformin extended release Sulphonylurea: Chlorpropamide (Diabenese) Tolbutamide (Orinase) Glimepride (Amaryl) Glipizide (Glucotrol) Glyburide (DiaBeta, Micronase) Meglitinides: Repaglinide (Prandin) Nateglinide (Starlix) Thiazolidindiones: Rosiglitazone (Avandia) Pioglitazone (Actos) Alpha-glucosidase inhibitors: Acarbose (Precose) Miglitol (Glyset) Dipeptidyl peptidase-4 (DPP-4) inhibitors Sitagliptin (Januvia) Saxagliptin (Onglyza) Non-insulin injectables Drug Class: Generic (Trade name) Exenatide (Byetta) Pramlintide (Symlin) Mechanism of action Decreases hepatic gluconeogenisis, increases insulin sensitivity Stimulate insulin secretion, decrease insulin resistance Stimulates pancreatic insulin secretion Regulates carbohydrate and lipid metabolism, reduces insulin resistance and hepatic glucose production Reduce the intestinal absorption of ingested glucose Reduces breakdown of GI hormone-incretins (glucagon-like peptide type-1, potentiates insulin secretion, decreases glucagon Mechanism of action Synthetic form of exendin 4, which has actions similar to glucagon-like peptide type-1 (GLP-1). Suppresses glucagon secretion and hepatic glucose production Suppresses appetite Delays gastric emptying Synthetic form of amylin, a naturally occurring peptide that is co-secreted with insulin by beta cells. Suppresses postprandial glucagon secretion and hepatic glucose production Potentiates the effects of insulin Suppresses appetite Delays gastric emptying Half life (h) Adverse effects Diarrhea, nausea, vomiting, lactic acidosis (avoid in renal & liver disease, CHF) 2-10 Hypoglycemia (caution in elderly & renal disease), Gastrointestinal disturbance 1 Hypoglycemia, but less common compared with sulfonylureas 3-8 Fluid retention, increased cardiac risk including CHF. Hepatotoxicity 2-4 Gastrointestinal irritation, flatus 8-14 Infection Half life (h) Adverse effects 6-10 Nausea, vomiting, weight loss, hypoglycemia when combined with sulfonylureas 2-4 Nausea, vomiting, weight loss, hypoglycemia with insulin

5 Pharmacology of Insulin. Drug Class: Generic (Trade name) Onset Peak Effect Duration Short-acting and Rapid-acting Regular (Novolin R, Humulin R) min 2-4 h 6-8 h Lispro (Humalog) 5-15 min min 4-6 h Aspart (Novolog) 5-15 min min 4-6 h Glulisine (Apidra) 5-15 min min 4-6 h Intermediate-acting NPH (Novolin N, Humulin N-NF) 2-4 h 4-10 h h Zinc insulin (Lente) 2-4 h 4-10 h h Extended zinc insulin (Ultralente) 6-10 h h h Long-acting (peakless) Glargine (Lantus) 2-4 h None h Detemir (Levemir) 2-4 h None h Mixed Insulins (NPH + Regular) 70% NPH/30% Regular (Novolin 70/30, Humulin 70/30) min Dual h 50% NPH/50% Regular (Humulin 50/50) min Dual h Mixed Insulins (Intermediate-acting + Rapid-acting analogs) 70% Aspart Protamine Suspension/30% Aspart (Novolog Mix 70/30) 75% Lispro Protamine Suspension/25% Lispro (Humalog Mix 75/25) 50% Lispro Protamine Suspension/50% Lispro (Humalog Mix 50/50) 5-15 min Dual h 5-15 min Dual h 5-15 min Dual h

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