Conflict of interest Type 1 diabetes >20 years - age 23 Pens: -Aspartate insulin (Novorapid): GM human; 3 X 12 units -Glargine (Lantus): GM human: 36 units nocte -BSL – Glucometer 5 seconds: digital + log Gerich, Am J Med, 2002

Topics: New role for HbA1c New insulins Perioperative glucose control

Frequency perioperative diabetes REASON study 4,150 older inpatients 23 hospitals ANZ 22% diabetes, 30-day mortality 5% (OR 1.0) -27% IHD (20% all) -26% CRI (16% all) Story et al, Anaesthesia, 2010

Diabetes diagnosis Random BSL >11mmol/L Fasting BSL ≥ 7 mmol/L OGTT 2hr BSL >11mmol/L –Diabetes likely –Diabetes unlikely –Impaired glucose tolerance, >5.5 mmol/L Diabetes Australia + RACGP, Diabetes Management, 2009

Diabetes “severity” Using haemoglobin A1C: HbA 1c “A1C” Hb + glucose irreversibly attached to beta chain A1C - 3 months; <30 days 50%, 60 to 120 days 25% A1CMean BSL 6% 7.5 mmol/L 7% 9.5 mmol/L 8% 11.5 mmol/L 9%13.5 mmol/L 10%15.5 mmol/L Burtis et al, Tietz Textbook Clinical Chemistry, 2006

Not acute Type 1 RBG > 11 mmol/L diagnostic Diabetes Care, 2009 Endorsed by Diabetes Society of Australia

A1C ≥6.5% DM, 6.0% to 6.4% Intolerance Diabetes Care, 2009

Medical Journal of Australia 2011 Flinders % (262/2360) undiagnosed 666 surgical patients 52 (8%) known diabetes 54 (8%) unknown diabetes

Surgery, A 1C and infection 490 diabetic patients, non-cardiac VA Conneticut Median age 72, median A1C 7.3% A1C < 7.0%, n= 197, infection 12% A1C ≥ 7.0%, n= 293, infection 20% Adjusted OR A1C ≥ 7.0%, infection OR 2.1 (1.2 to 3.7) Dronge et al, Arch Surg, 2006

Ann Thorac Surg, 2009

New Insulins Killen et al, Anaesth Intensive Care, 2010

Insulin Pumps Basal rapid acting infusion + boluses Killen et al, Anaesth Intensive Care, 2010

Hypoglycemia Variation between and within US mg/dl = mmol/L X 18 approx mg/dl = 11.1 mmol/L (approx 10 mmol/L) Reference Range: 4 mmol/L to 6 mmol/L 3 mmol/L – sympathetic – sweating, hunger 2.5 mmol/L – altered CNS: confusion, diplopia Eventually coma, death Service, NEJM, 1995

Perioperative diabetes Limited evidence Glister + Vigersky, Endocrinol Metab Clin N Am, 2003 Ask patient: “What and when” - sugar and insulin Three parts: -Basal: glargine – avoids ketosis (cf GIK) -Nutritional – rapid (W/H) -Corrective –rapid s/c or IV regular Assundi + Calles-Escandon, J Hosp Med, 2007 Killen et al, Anaesth Intensive Care, 2010

Dumb things with insulin Forget to take it Take twice –short –long Take wrong one Take too much Eat too much for usual dose Eat too little for usual dose Unusual and/or stressful situations

Insulin pumps Beware: Technology + no underlying long acting Options: IV regular infusion at basal rate (day surgery) Continue with pump if confident Convert to s/c rapid + glargine Assundi + Calles-Escandon, J Hosp Med, 2007 Killen et al, Anaesth Intensive Care, 2010

Perioperative diabetes Measure the blood sugar

What BSL? Aim: 8 mmol/ L (5 to 10 mmol/L) NICE-SUGAR: 6000 ICU patients 4.5 to 6.0 mmol/L (tight) vs <10 mmol/L (usual) 90 day mortality, Tight control surgical OR: 1.31 Hypos 6.8% vs 0.5% NICE-SUGAR Investigators NEJM, 2009

Hypo…how much dextrose? Mild to mod: 3 to 5 mmol/L; severe < 3 mmol/L Don’t over treat: target 8 mmol/L (5 to 10 mmol/L) –Dextrose 5% = 5 g/100ml –Dextrose 50% = 50 g/100 ml = 5g/10 ml IV push BSL 3-5 Dose = 0.1 g/kg 2ml/kg 5% dextrose BSL < 3 Dose = 0.15 g/kg 3ml/kg 5% dextrose Can’t remember = 150 ml 5% Dextrose (7.5g) = 15 ml 50% Assundi + Calles-Escandon, J Hosp Med, 2007

You can drink D5W …but the taste isn’t great

Why is the patient hypo? Poor management: eg delay Mistake in insulin or intake? Is the problem fixed? –beware duration too much long-acting Beware insulin infusions

Most likely…hyperglycemia My glucometer on Christmas day…

Most likely…hyperglycemia BSL > 10 mmol/L Hours: unpleasant hyperosmolar, dehydrated Don’t over treat; target 8 mmol/L (5 to 10 mmol/L) 80/total daily insulin = 1 unit effect mmol/L BSL Me: 72 units / day 80/72 = 1.1 mmol/L for 1 unit Adult rule of thumb: BSL - 8 = IV regular insulin OR S/C rapid Glister + Vigersky, Endocrinol Metab Clin N Am, 2003

Then 15 minutes later… Measure the blood sugar

Postop Physicians Three parts (alternative to insulin infusion) 0.5 units / kg / day (conservative start) -Basal: glargine 0.25 units / kg / day -Nutritional –rapid s/c 0.25 units / kg / day -Corrective – rapid s/c RABBIT 2, Diabetes Care 2011 Assundi + Calles-Escandon, J Hosp Med, 2007

Higher A1C less tolerant of lower glucose Egi et al, Crit Care Med, 2010

Acclimatization

Concluding thoughts… Balance of probabilities: A1C in all coronary + vascular patients ?A1C in others eg 70+ No DM + A1C >6% - med review – risks A1C >8% +/- DM - med review Research: A1C in ANZ populations: complications :RCT usual care vs A1C < 7.0 preop Measure the blood sugar

Concluding thoughts… No evidence for very tight control in OR Aim: 8 mmol/L (Range: 5 to 10 mmol/L) Give basal W/H rapid Don’t overreact Use IV regular or s/c rapid to correct Beware pumps Antiemetics D5W is our friend Endocrine involvement for O/N stay Measure the blood sugar Ahmed et al, Anaesth Analg, 2005

You forgot to measure the blood sugar?!? Thanks