1. Perioperative Care For the General Surgical Patient Dr.Raed AlAsmi SAU MC

2. Pre-operative issues- Dr. Lester Intraoperative glycemic control- Dr. Kyper In-Patient management of diabetes in the hospital- Dr. Sherington

3. Pre-operative Objectives: Pre-operative evaluation of the diabetic patient Assessing Pre-operative glycemic control Does pre-op glycemic control correlate with outcomes Recommendation for glucose management pre-op How common is unrecognized diabetes

4. Pre-operative Recommendations for Patients with Diabetes Goal: Maintain euglycemia while minimizing risks for hypoglycemia and other drug related complications Decrease length of stay and risk of infections

5. Patients with diabetes: what pre-operative assessment is important? Document the following Type of diabetes Length of time since diagnosis Current management Current glycemic control HgBA1c Glucometer dta Presence of complications Neuropathy Nephropathy Retinopathy Autonomic neuropathy increase risk of post op gastroparesis and urinary tract infection

6. Why is pre-op glycemic control important? Poor glycemic control Increases dehydration and electrolyte abnormalities Impairs collagen formation and decreases surgical wound strength Increases risk of complications Medications for diabetes management associated with risks

7. Can patients stay on their pre admission therapy? Answer: It depends on the patient, the type of surgery and which therapy they are on

8. What about metformin? Metformin is most commonly prescribed medication for type 2 DM 33% of prescriptions in 2001 Bigaunides associated with an increased risk of lactic acidosis phenformin resulted in 306 cases of lactic acidosis over a 26 year period

9. Copyright restrictions apply. Duncan, A. I. et al. Anesth Analg 2007;104:42-50 A Comparison of Matched Metformin and Nonmetformin Treated patients on Continuous Outcome Variable

10. Other oral agents? Oral Agents TZDs- rosiglitazone or pioglitazone Used to improve insulin sensitivity Sulfunylureas-glipizide, glyburide or glimeperide Insulin secretagogues, non glucose dependent DPP-4 Inhibitors Sitagliptin (Januvia) Work to slow food absorption, enhance insulin release in glucose dependent manner Potential Complications Increased risk of fluid retention and hypoglycemia Increased risk of hypoglycemia No known risks

11. Clinical example 87 y/o female with type 2 DM, HTN, COPD Admitted for cholecystectomy 2 nd Hospital day routine AM lab plasma glucose level of 45 mg/dL, patient confused, responded to IV glucose Reason for hypoglycemia ? On going use of glyburide

12. Recommendations for out patient oral agents Discontinue all diabetic medications on admission Insulin must be continued in all type 1 patients Can re-order short acting sulfonylureas (glipizide, glimeperide) and TZDs in very stable patients Consider insulin therapy for all unstable patients, including those with renal insufficiency or NPO status

13. Management of Type 1 Diabetes prior to Minor Surgery Procedures Day of procedure if the patient is NPO: Patient to take basal insulin as scheduled No bolus insulin- short acting insulin including lispro, aspart and glulisine Measure capillary glucose levels prior to procedure and every 2–4 hours. Administer short-acting or fasting insulin subcutaneously every 2–4 hours as indicated Day of procedure if breakfast is allowed: Patient to take basal insulin as scheduled Can take bolus insulin with morning meal Measure CBGs before and after procedure. Patients on continuous insulin infusion (insulin pump) continue with basal rate no bolus should have hospital guidelines on use of personal insulin pumps

14. Preoperative management of patients with type 2 DM Check HgBA1c prior to surgery Hold oral agents on day of surgery Check fasting blood glucose If less than < 180 no use short acting insulin for correction If greater than 180, consider insulin infusion Check HgBA1c and fasting blood glucose Hold oral agents on day of surgery Patients with fasting blood glucose < 180 ½ of intermediate insulin in am Give normal dose of glargine Patients with fasting blood glucose > 180 consider insulin infusion Non insulin treated patient Insulin treated patient

15. Clinical Example 56 y/o male, no prior history of medical problems Involved in MVA requiring emergency surgery for open femoral fracture POD # 3 routine AM glucose elevated at 230 mg/dL Is this stress or hospital associated hyperglycemia? What are the implications?

16. What about undiagnosed diabetes? Prevalence of DM in hospitalized patients- 12-26% Prevalence of inpatient hyperglycemia- 38% (chart review of 1886 medical and surgical pts at community teaching hospital) 1/3 with newly discovered hyperglycemia 20-30 % of patients with diabetes are undiagnosed References: Clement S, Braithwaite SS, Magee MF, et al. Management of diabetes and hyperglycemia in hospitals. Diabetes Care. 2004;27(2):553-91. Umpierrez GE, Isaacs SD, Bazargan N, You X, Thaler LM, Kitabchi AE. Hyperglycemia: an independent marker of in-hospital mortality in patients with undiagnosed diabetes. J Clin Endocrinol Metab. 2002;87(3):978-82.

17. Relationship between perioperative glucose and postoperative infection Stress or new hyperglycemia associated with higher in hospital mortality rates (16%) compared with prior history of diabetes

18. Screening adults for diabetes prior to surgery Pilot study for 2 weeks 261 patients evaluated 200 without documented diabetes Mean CBG lower in non DM But range up to 212 24/200 with CBG > 126

19. Using POC HGBA1c and CBG Measurements 4 week pilot on cardiovascular intervention unit 146 pts without DM 34 patients with DM Mean fasting CBG No DM=109 DM=145 HgBA1c correlates but with lower fasting CBG

20. Hospitalization can identify patients with unrecognized diabetes allow appropriate therapy to begin Hyperglycemia on admission worsens outcomes in patients with CABG HgBA1c predicts poor outcomes in trauma Importance of unrecognized diabetes

21. Identifying At risk Patients Hyperglycemia from poorly controlled diabetes or in patients with unrecognized diabetes can increases hospital related morbidity and mortality Elevated HgBA1c indicates need for post hospital therapy change in patients with diabetes increases the likelihood of needing therapy after hospitalization Must have routine monitoring of glucose levels and HgBA1c to identify patients Recommend CBG monitoring on all surgical patients for first 24-72 hours Add HgBA1c to admission labs for all patients with diabetes add for patients that have two CBGs > 140

25. Intra-operative Glycemic Control Robert Kyper MD Columbia Anesthesia Group October 12, 2007

27. Dr. Evil Says….

28. History of Glycemic Control Anesthesiologist goals: Avoid hypoglycemia & severe hyperglycemia No point of care testing Insulin given IV or SQ to few patients

29. Textbook Training Anesthesia and Co-existing Disease, 4th Edition, Stoelting & Dierdorf (2002) Consensus that IDDM patients undergoing surgery be treated w. insulin NO evidence that close glucose control in relatively brief intraoperative period benefits diabetic patients.

30. Recently… Martinez, EA, Williams, KA, Pronovost, PJ (2007). Thinking Like the Pancreas, Anesthesia and Analgesia, 104, 4-6. In the last 5 years most hospital based physicians including anesthesiologists have NOT changed their practices in regards to glycemic control

31. Anesthesia Literature Numerous studies, Cardiac surgery Numerous studies, ICU pts. (the sick) Injured/ischemic brains Notable lack of data for Ortho./ General

32. Am. College of Endocrinologists & ASA Guidelines 1. Keep glucose below 180 2. Maintain glucose 80-110 in ICU pts. 3. Avoid PO hypoglycemic drugs unless pt. on regular diet 4. Provide basal insulin for those who are insulin deficient 5. Create and implement a hypoglycemia prevention and management protocol

33. Day of Surgery: How sweet it is. Data from: Vivek K. Moitra, VK, Jason Greenberg, J, & Sweitzer, BJ (2005). Hyperglycemia on the Day of Surgery. ASA Abstracts Preoperative Blood Glucose Readings

34. Day of Surgery -Then Criteria for postponing surgery Lack of data for general surgery pts Decreasing surgical risk Greatest risks for bowel surgery, implants, large incisions, brains, carotid, spines

35. Barriers D5 containing fluids Dexamethasone (steroid) PONV ppx Stress dose steroids Insulin availability Glucometer availability Hemodynamic management Duration of surgery

36. Dexamethasone continued 54 yo Male for Thyroidectomy, Type 2 DM Preop. CBG = 169 10 mg desamethasone intraop. Poor post op control on sliding scale and usual scheduled NPH dosing Peak CBG = 390; 10PM that day No complications recorded at discharge

37. Metformin Risk of lactic acidosis Rare, yet mortality of 50% Probably benefits out weigh risks Does not increase in-hospital mortality after cardiac surgery Duncan, Anesth Anal 2007; 104:42-50 Complications were lower Less: prolonged intubation, infection, overall morbidities

38. Infections Bacterial exposure in OR Highest rates after abdominal surgery More common, CABG, C-section, Vascular, Joint prosthesis, spinal fusion Most common pathogens are normal skin flora One to One pt. / provider care Manage Antibiotics, temp., glycemic control

39. Insulin Pumps Basal insulin need Leave in running if possible May need to remove for positioning, or surgical field If removed, insulin infusion for longer surgery

40. Guidelines - Elective Surgery CBG <200, proceed Insulin infusion (>3hr.) CBG 200-349 treat, and Anesthesiologist discussion with Surgeon, (proceed or delay) CBG ≥ 350, postpone surgery until CBG improved

41. Checking Intra-operatively Duration ≤ 1 hr - check if time allows Duration ≥ 2 hr - check at least once, preferably Q1hr Pt. with CBG ≤ 90 check Q1hr Craniotomy patients, check at least once Craniotomy patients (diabetic, CBG ≥ 120, or steroid given) check Q1hr

42. Avoiding Increases in Blood Glucose Avoid boluses of D5 containing IV fluid Pre-op. nurses Hanging 500 ml bags of D5LR More readily identifying IVF as something other than LR Reducing the dose Dexamethasone; avoid or reduce dose Consider insulin infusion post operatively, if given Alternatively NPH insulin dose and sliding scale coverage

43. Insulin Administration in the OR How aggressive? Keep glucose < 180 4 Column infusion IV boluses Useful for short cases in place of drip Useful to augment infusion in longer cases

44. Transitions Considered problematic for many aspects of patient care, including glycemic control Insulin infusions to PACU, possibly to floor Coordination with glycemic control team

49. Peri-operative Care for the General Surgical Patient: The Pharmacist’s Role Sarah L. Sherington PharmD Glycemic control/surgical services Southwest Washington Medical Center

50. Management of the Surgical Patient Pre operative Instruction sheet given to all diabetics Hold oral diabetic medications day of surgery Give full dose of glargine (Lantus®) the night before surgery Give half usual dose of NPH or regular insulin day of surgery In order to reduce complications such as infection, you may be given insulin during your hospitalization, even if you are not currently using insulin.

51. Identifying The Diabetic Patient Surgery schedule identifies known diabetic patients Scheduling form changed Diabetic yes/no Blood glucose on all patients admitted for inpatient surgery unless documented fasting blood glucose less than 130mg/dl

52. Glycemic Control Management Standardized Insulin Infusion 1unit/ml Pre operative orders changed Correction dose insulin orders using insulin aspart Insulin infusion prepared for surgeries over 3 hours Intra operative management: insulin infusion using the 4 column infusion protocol Post operative management Correction dose insulin orders using insulin aspart Insulin infusion

53. Glycemic Control Pharmacist Identifies all surgery patients who are diabetic or have a recorded elevated blood glucose Surgery patients include all patients admitted to the two surgery floors or medical/surgery floor not followed by a PCP and all CABG patients transferred from CCU Resource for physicians and nurses with patients with poor glycemic control

54. Inpatient Management of Hyperglycemia Hold oral diabetic medications Order bmp for all patients on metformin Intravenous insulin therapy Best therapy for patients with a critical illness, changing status or severe hyperglycemia Scheduled insulin Basal and prandial/nutritional insulin Supplemental insulin Increase in daily insulin requirement attributed to illness, stress or treatment

57. Average Length of Stay

58. Questions?