9/23/09. What are the key components of preoperative, intraoperative, & postoperative care of diabetes management? Rebecca L. Sturges, M.D.

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1 RMHS Perioperative Summit: Perioperative Diabetes Management Rebecca L. Sturges, M.D. Oct 6, 2009 Mrs. B was referred by her orthopedic surgeon to your preoperative clinic to discuss medical management of her diabetes with her upcoming elective TKA. What are the key components of preoperative, intraoperative, & postoperative care of diabetes management? Define prevalence of DM in surgical population Understand the implications of DM in the perioperative period Explore the impact of surgery and DM Management of DM thru continuum of perioperative period 1

General Population 7.8% of population has DM (23.6 million) 12.

26% w/ known DM 12% no prior hx 40 35 30 25 20 15 10 5 0 7.

2 General Population 7.8% of population has DM (23.6 million) % of all hospitalized adults Surgical Population ~1/3 rd hyperglycemic 26% w/ known DM 12% no prior hx % General Population 38% 3.6% Surgery Preoperative Population Evaulation No Dm Dx DM Dx Surgery & Anesthesia 2

3 Longer LOS Higher health care resource utilization Expenditures 2.3x greater Hospital Care Costs: Diabetic vs nondiabetic Greater perioperative mortality ACTIVELY maintain normoglycemia, avoid highs and lows MAINTAIN fluid & electrolyte balance PREVENT development of ketoacidosis (DM-1) IDENTIFY specific glycemic goals Correction Nutritional Prandial Basal 0 Healthy Sick/ Eating Sick/NPO 3

4 Basal: Targets fasting hyperglycemia Nutritional: Targets IV dextrose, TPN, enteral feeds, nutritional supplements, or meals (prandial) Correction: supplemental insulin for hyperglycemia Prospective, multicenter, randomized trial Insulin-naive type 2 diabetic pts on general medicine Compared basal-bolus vs. SSI Primary end point: mean daily blood glucoses Secondary outcomes: # hypoglycemic events, # events severe hyperglycemia, LOS, & mortality rate Basal-bolus Total Daily Dose=0.4 or 0.5 u/kg x pt s wt (kg) Basal:bolus=50:50 e.g. Wt=70kg TDD=0.4u/kg x 70kg = 28 units Basal dose=14 units Bolus dose=14 units (~5 units AC) 4

5 TDD Basal-bolus 22+/-2 (basal) 20+/-1 (bolus) SSI 12.5+/-2* Goal Mean Glc 66% 38%* Mean Glc 166+/ / / /-54* 165+/=41* 188+/-45* Hypoglycemia 3%(0.4%) 3%(0.2%) Hyperglycemia 0% 14%* Glycemic control rapidly improved after switching to basal-bolus regimen after persistent severe hyperglycemia despite increasing doses of RISS. Noncritically Ill Patients Goals: premeal <140 mg/dl + all random <180mg/dl Adjust for prior control, goals of care, severe comorbidities Preferred Agent: SQ insulin (basal + nutritional + correction) Critically Ill Patients Preferred Agent: IV Insulin Goals: mg/dl (target closer to 140mg/dl) Avoid values <110mg/dl 5

6 Conventional Glucose Control Target: < 180 mg/dl Mean: 144 +/- 23 mg/dl Death: 24.9% Intensive Glucose Control Target: mg/dl Mean: 115 +/- 18 mg/dl Death: 27.5% NICE-SUGAR.should NOT lead to an abandonment of the concept of good glucose management in the hospital setting...compared to a control group whose glucose control was good (average glucose 144 mg/dl)..reasonable for clinicians to treat critical care patients with the less intensive, yet good-glucose control strategies used in the conventional arm. Perioperative Management: Recommended Insulin Regimen Pre-Op Basal + SS Intra-Op IV Insulin Post-Op IV Insulin Basal + SS +/- Nutritional 6

fluid retention Insulin Diabetic Control prior to OR A1c Diet-controlled FBG check prior to OR + SS Oral Rx Hold am of surgery FBG check prior to

7 Diabetic type I: need basal insulin II: +/- basal insulin Surgery Characteristics Type (Major vs Minor) Timing Duration Anesthesia (epidural vs general) Outpatient Diabetic Rx Diet-controlled Oral agents Secretagogues -> hypoglycemia Biguanides -> lactic acidosis Thiazolidinediones -> fluid retention Insulin Diabetic Control prior to OR A1c Diet-controlled FBG check prior to OR + SS Oral Rx Hold am of surgery FBG check prior to OR + SS +/- Basal ( u/kg) Insulin NPH: ½ am dose + D5 + SS Glargine: 100% dose + SS Insulin Pump: cont basal rate ****insulin gtt for MAJOR OR 7

Uncomplicated post-op course No further OR needed No contrasted studies Starts at admission

8 VII: Honor Thy Turf (Or Thou Shalt Not Covet Thy Neighbor s Patient Transition to SQ insulin Address basal, nutritional, & correction needs Consider restarting Oral Rx Tolerating PO well Uncomplicated post-op course No further OR needed No contrasted studies Starts at admission Prior Dx of DM/Hyperglycemia Management of DM Prior glycemic control (A1c) Resource availability 8

Survival Skills Education 1. Level of understanding 2. Home BG goals & monitoring 3. S/Sx of hyper/ hypoglycemia, prevention & treatment 4. Outpt MD 5. Eating patterns 6. Rx management 7.

9 Survival Skills Education 1. Level of understanding 2. Home BG goals & monitoring 3. S/Sx of hyper/ hypoglycemia, prevention & treatment 4. Outpt MD 5. Eating patterns 6. Rx management 7. Sick-day management 8. Needle/syringe disposal PCP F/u w/in 1 month Communication w/ PCP Diabetes is VERY prevalent in the surgical population Diabetes IMPACTS surgical outcomes Multiple INTERACTIONS between diabetes and surgery Requires ACTIVE management thru continuum of perioperative period 9

Questions? Clement et al. Management of Diabetes and Hyperglycemia in Hospitals. Diabetes Care 2004; 27(2): 553-591. CDC.

10 Questions? Clement et al. Management of Diabetes and Hyperglycemia in Hospitals. Diabetes Care 2004; 27(2): CDC. National diabetes fact sheet:general information and national estimates on diabetes in US, Atlanta, GA: U.S. Dept of Health & Human Services, CDC Dronge et al. Long-term Glycemic Control and Postoperative Infectious Complications. Arch Surg 2006; 141: Estrada et al. Outcomes and Perioperative Hyperglycemia in Patients With or Without Diabetes Mellitus Undergoing Coronary Artery Bypass Grafting. Ann Thorac Surg 2003; 75: Furnary, A.P. & Y.X. Wu. Clinical Effects of Hyperglycemia in the Cardiac Surgery Population: The Portland Diabetic Project. Endocrine Practice 2006; 12(3) Goldman et al. Ten Commandments for Effective Consultations. Arch Intern Med 1983; 143: Lai et al. Presence of Medical Comorbidities in Patients with Infected Primary Hip or Knee Arthroplasties. The Journal of Arthroplasty 2007; 22(5): Metchick et al. Inpatient of Diabetes Mellitus. The American Journal of Medicine 2002; 13: Meneghini, L. & I.B. Hersch. Pharmocotherapies for Diabetes Management: An Update for the Practicing Clinician. Semin Thorac Cardiovasc Surg 2006; 18: Moghissi et al. American Association of Clinical Endocrinologist and American Diabetes Association Consensus Statement on Inpatient Glycemic Control. Endocrine Practice 2009; 1(4): Roberts et al. Prevalence of Hyperglycemia in a Pre-Surgical Population. The Internet Journal of Anesthesiology 2007: 12(1). Smiley, D.D. & G.E. Umpierrez. Perioperative Control in the Diabetic or Nondiabetic Patient. Southern Medical Journal 2006; 99(6): The NICE-SIGAR Study Investigators. Intensive versus Conventional Control in Critically Ill Patients. NEJM 2009; 360(13):

Deepika Reddy MD Department of Endocrinology

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