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Peri-Operative Diabetic Patient Management. Larry Field, MD Critical Care Anesthesiologist Medical University of South Carolina. April 20, 2010. Objectives. Update our knowledge of different insulin preparations Update our knowledge of non-insulin (oral and injectable) agents

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Peri-Operative Diabetic Patient Management

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Peri-Operative Diabetic Patient Management

Larry Field, MD

Critical Care Anesthesiologist

Medical University of South Carolina

April 20, 2010


Objectives

  • Update our knowledge of different insulin preparations

  • Update our knowledge of non-insulin (oral and injectable) agents

  • Set reasonable goals for perioperative glycemic control

  • Suggest recommendations for achievement of glycemic goals

  • Disclaimers: None


Diabetes Mellitus

  • Metabolic diseases characterized by hyperglycemia resulting from defects in insulin secretion, insulin action, or both

  • Affects 8% of general population

  • 20% of persons aged 65 to 74

  • 30-40% of those born this past decade

JAMA 2003;290:1884–90

Curr Opin Anaesthesiol 22:718–724


Insulin Regimens

  • Humalog/ Novolog

  • Humalin/ Novolin

  • Lantus

  • Levemir (detemir)


Non-insulin Agents


Alpha-glucosidase inhibitors

  • Acarbose (Precose), miglitol (Glyset)

  • Inhibit oligosaccharide and disaccharide uptake at intestinal (brush border) level

  • If NPO, doesn’t do anything


Biguanide

  • Metformin (Glucophage)

  • Inhibition of gluconeogenesis in the kidneys and liver

  • Bind to the Mitochondrial membranes, leading to decreased ATP and increased AMP

    • Limited hypoglycemia potential

    • Lactic acidosis black box warning

    • Classically hold for 48hrs

  • Eliminated by kidneys


Diabetes Care 2004; 27:1791-1793


Sulfonylureas

  • Endogenous insulin release from beta cells

    • Can cause hypoglycemia

    • Hold on morning of surgery

www.endotext.org


Meglitinides

  • Nateglinide (Starlix), repaglinide (Prandin), repaglinide/metformin (PrandiMet)

  • Induce endogenous insulin release similar to sulfonureas

    • Hypoglycemic risk reduced?

  • Quick/short action

  • Taken prior to each meal


Thiozolidinediones (glitazones)

  • Troglitazone (Rezulin), rosiglitazone (Avandia), pioglitazone (Actos)

  • Transcription factor (PPAR)agonist

     Insulin receptor sensitization

    • Also improves lipid profiles

    • No lactic acidosis

    • Limited potential for hypoglycemia

    • Hepatotoxicity and fluid retention concerns

  • Short plasma half-life; Long duration of action


Combination Pills


Incretin hormones?

  • GI hormones released in response enteral carbohydrate load

  • Glucose-dependent insulinotropic polypeptide (GIP)

    • Increased insulin release from beta cells prior to hyperglycemia

  • Glucagon-like peptide 1 (GLP-1)

    • Neuroendocrine signal


GLP-1

  • Alpha cells:

    • Glucose-dependent glucagon inhibition

  • Beta cells:

    • Primes glucose-dependent insulin release

    • Increases beta cell numbers

    • Increases insulin biosynthesis

  • Reduces appetite; slows gastric emptying


Dipeptidyl peptidase IV

  • Ubiquitous

  • Involved in hormone degredation

    • GLP-1, VIP, GHRH, neuropeptide Y

    • GLP-1 is quickly degraded

  • Involved in immune cell messaging


Amylin

  • Produced by pancreatic beta cells similar to insulin

  • Independent/additive effects to insulin

  • Glucose-dependent glucagon suppression

  • Satiety and delayed gastric emptying


Newest Agents

SQ

PO

SQ

Little anesthetic experience with these agents

Based on physiology and pharmacology

Anesth Analg 2009;108:1803–10


Surgery as a Metabolic Challenge

  • Stress hormones – catecholamines, cortisol, growth hormone

  • Cytokines – IL-6 and TNF-alpha

  • Hyperglycemia proportional to insult

    • Superficial: 10-20 mg/dl

    • Major vascular/cardiac: 50-100 mg/dl


Stress-induced hyperglycemia

  • Adaptive response

  • Brain and red blood cell uptake is increased

  • Independent risk factor for morbidity and mortality


Hyperglycemia

  • Impaired collagen production

  • Impaired neutrophil chemotaxis, phagocytosis, and bacterial killing

  • Increased platelet aggregation

  • Infectious complications

Clinical Diabetes 2009; 27:82-85


Hypoglycemia

  • Sympatho-adrenal activation

  • Diaphoresis, tachycardia, hypertension

  • Weakness/fatigue  AMS  Coma

  • Common in Type 1 diabetics

  • Uncommon in Type 2 diabetics


Intraoperative Glucose Control Data

  • Sparse data on outpatient procedures

  • Critical care data

    • Van den Berghe 2001  80-110 goal

    • NICE-SUGAR  140-180 goal

  • Cardiac/surgical data

  • Very tight vs good vs poor glucose control


Insulin Benefits

  • Decreases endothelial activation

  • Improved lipid profiles

  • Decreases pro-inflammatory cytokine production

  • Benefits thought due to glycemic control


Treatment Goal

  • Try to mimic normal metabolism as closely as possible:

    • Avoiding hypoglycemia

    • Avoiding excessive hyperglycemia

    • Avoid ketoacidosis

    • Avoid electrolyte/fluid disturbances

    • Avoid large fluctuations


Consensus Recommendations

Typical daily insulin regimen

(DM Type 1: about 50% of daily insulin is basal)

Consensus Statement, SAMBA 2010


Consensus Recommendations

Consensus Statement, SAMBA 2010


Consensus Statement, SAMBA 2010


Consensus Recommendations

Consensus Statement, SAMBA 2010


Consensus Recommendations

Consensus Statement, SAMBA 2010


Consensus Recommendations

Consensus Statement, SAMBA 2010


Consensus Recommendations

Consensus Statement, SAMBA 2010


POC testing can be off by +/- 20%

  • 20% of capillary

  • 7% of whole blood samples

Mayo Clinic Proc. 2008; 83:394-397


Consensus Recommendations

Insulin admin: IV gtt vs IV bolus vs SQ bolus?

Consensus Statement, SAMBA 2010


Insulin Dosing

  • Use 1500 rule for regular insulin

  • Use 1800 rule for rapid-acting insulin

Current opinion in anesthesiology 2009; 22:718-724


Consensus Recommendations

Consensus Statement, SAMBA 2010


Current opinion in anesthesiology 2009; 22:718-724


Other Anesthetic Considerationsfor Diabetes Mellitus

  • Diabetic comorbidities not covered today

  • Periop/stress steroids

     Hyperglycemia within a couple of hours

  • Starvation increases insulin resistance

     Preop carb loading may help

  • Beta-blockers can blunt catecholamine-induced hyperglycemia


Other Anesthetic Considerationsfor Diabetes Mellitus

  • Etomidate can blunt steroid-induced hyperglycemia of stress

  • Volatile anesthetics impair insulin release and increase insulin resistance (dose-dependent)

  • Regional anesthesia/local anesthetics can blunt/abolish periop hyperglycemia

  • High-dose opioids also blunt


A Final Thought

Continuous glucose monitoring will (soon) be awesome!


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