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Perioperative Diabetes Management. Dr. Ken Locke March 2007. Objectives. At the end of the seminar, you will be able to: Describe the problems created by inadequate perioperative glycemic control Develop a series of goals in the perioperative management of diabetes, and prioritize them

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Perioperative Diabetes Management

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Perioperative diabetes management l.jpg

Perioperative Diabetes Management

Dr. Ken Locke

March 2007


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Objectives

At the end of the seminar, you will be able to:

  • Describe the problems created by inadequate perioperative glycemic control

  • Develop a series of goals in the perioperative management of diabetes, and prioritize them

  • Explain strategies for managing diabetes, and apply them to clinical cases


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Outline

  • Clinical cases

  • Background on perioperative hyperglycemia

  • Principles of perioperative diabetes management

  • Recommendations

  • Cases revisited


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Clinical Cases

  • A 25 year old type 1 diabetic woman is scheduled for hysteroscopy for infertility

    • What are the important considerations in her periop management?

    • What strategies could be used?


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Clinical cases cont.

  • A 72 year old man with type 2 diabetes on 150 units of insulin/day is scheduled for cataract extraction

    • What are the important considerations in his periop management?

    • What strategies could be used?


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Clinical cases cont.

  • A 58 year old type 2 diabetic woman on glyburide and metformin is scheduled for AAA resection

    • What are the important considerations in her periop management?

    • What strategies could be used?


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Why is perioperative glycemic control important?

  • Improvement in wound healing parameters (tissue level data)

  • Improvement in infection parameters (tissue level and case series)

  • Improved mortality seen in critical illness, post CV surgery, and post AMI with STRICT glycemic control (RCT level data)


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Why is perioperative glycemic control difficult?

  • Altered glucose inputs

    • NPO, changes in motility, enteral feeds, TPN

  • Altered hypoglycemic therapy

    • Cannot use OHAs

    • SC insulin may have different absorption profile

  • Altered glucose homeostasis

    • Increased counter-regulation in perioperative environment

    • Decreased ambulation

    • Increased tissue consumption after larger surgeries


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Principles of Perioperative DM Management

  • 1st Goal: Avoid intra-operative hypoglycemia

  • 2nd Goal: Avoid acute complications of hyperglycemia

  • 3rd Goal: Maintain optimum glycemic control


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Avoid Intraoperative Hypoglycemia

  • Hypoglycemia is potentially damaging at any time

  • Intraoperative hypoglycemia is impossible to detect clinically

    • Sympathetic responses are ablated by anaesthesia

  • Hypoglycemia is more likely intraoperatively

    • Increased glucose consumption in response to surgery


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Avoid Intraoperative Hypoglycemia

  • Solution: Support patients with IV D5W who take any pharmacologic DM therapy

    • Remember, yesterday’s evening doses are peaking during this morning’s OR!

  • Minimum is 5g of glucose/hour = 100 cc/hour

    • Also prevents catabolism


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Avoid Acute Complications of DM

  • Type 1 patients are prone to ketoacidosis

    • But Type 2 patients can develop it with great stress

  • Type 2 patients are at risk of hyperosmolarity

  • Risk of both of these increases with duration and complexity of surgery

    • Direct effects of counter-regulation and fluid balance


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Avoid Acute Complications of DM

  • Solution:

    • Ensure adequate insulin is present during surgery and afterward

    • Remember that insulin resistance in Type 2 patients may require dose increases

    • Monitor glucose before, during and after OR

    • Ensure appropriate fluids are being given to assist in glucose clearance


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Maintain Optimum Glucose Levels

  • Range of 8-11 typically used

    • Avoids hypoglycemia but not beyond range of control

  • Choose the strategy that fits:

    • type of surgery (metabolic stress)

    • duration of surgery

    • availability of resources


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Options

  • Rely exclusively on residual insulin from previous day’s therapy (oral or SC insulin)

    • Best for short procedures where risk of acute hyperglycemia is very low

  • SC long acting insulin (adjusted dose)

    • May not be adequate for longer procedures

  • IV insulin infusion with frequent monitoring of glucose level

    • Requires time/personnel to monitor and adjust


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Best Practices

  • All patients hold their usual doses on day of surgery while NPO

  • No agreement on anything beyond this!

  • IV insulin preferred to achieve optimum glucose control

    • Use for Type 1&2 DM, longer procedures, especially with significant insulin resistance

  • SC insulin when IV insulin not necessary

    • Can be more liberal with Type 2 than Type 1

  • “Yesterday’s insulin” – never for Type 1


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Postoperative Management

  • When patients resume eating, can usually resume usual therapy

  • Alterations (NPO, reduced diet, enteral feeds etc.) require altered management

  • Oral agents should wait until reliable diet

  • IV insulin easiest to titrate/achieve control

    • Remember to anticipate rather than react to abnormal glucose


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Back to the Cases

  • Develop a plan for each case:

  • A 25 year old type 1 diabetic woman is scheduled for hysteroscopy for infertility

  • A 72 year old man with type 2 diabetes on 150 units of insulin/day is scheduled for cataract extraction

  • A 58 year old type 2 diabetic woman on glyburide and metformin is scheduled for AAA resection


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