current approach to peri-operative control of blood sugar
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Current Approach to Peri-operative control of Blood SugarTRANSCRIPT
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Current Approach to Current Approach to
Peri-operative control of Peri-operative control of Blood Sugar Blood Sugar
Dr. Md. YunusDr. Md. YunusAdditional Professor & In Charge, Cardiac Additional Professor & In Charge, Cardiac Anesthesia division, NEIGRIHMS, Shillong Anesthesia division, NEIGRIHMS, Shillong
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What are the diagnostic yardsticks What are the diagnostic yardsticks
for DM?for DM?
What is impaired fasting glycemia?What is impaired fasting glycemia?
A BS of 180 mg.dlA BS of 180 mg.dl-1-1=How many =How many
mmol.Lmmol.L-1-1??
If venous BS is 110 mg.dlIf venous BS is 110 mg.dl-1-1, what is , what is
capillary BS?capillary BS?
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Reproducible demonstration of fasting Reproducible demonstration of fasting
hyperglycemia: FBS > 110 mg% (6.1 mmol Lhyperglycemia: FBS > 110 mg% (6.1 mmol L-1-1) )
(Serum/plasma sugar > 126 mg% [7 mmol L(Serum/plasma sugar > 126 mg% [7 mmol L-1-1, , OROR
A ‘casual’ (R) BS of > 180 mg% [10 mmol LA ‘casual’ (R) BS of > 180 mg% [10 mmol L-1-1], OR], OR
Oral GTT producing a result in the diabetic Oral GTT producing a result in the diabetic
range range
BS concentrations between 100 – 110 mg% (5.6-BS concentrations between 100 – 110 mg% (5.6-
6.1 mmol L6.1 mmol L-1-1) ) ‘impaired fasting glycemia’ ‘impaired fasting glycemia’
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Diabetes (WHO criteria)
Diagnosed by a random plasma glucose Diagnosed by a random plasma glucose
>11.1mmol/l & a fasting >11.1mmol/l & a fasting
glucose>7.0mmol/lglucose>7.0mmol/l
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What are the factors affecting the What are the factors affecting the peri-operative anesthetic peri-operative anesthetic
management of DM?management of DM?
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Type of DMType of DM MedicationMedication End-organ changes End-organ changes Nature of surgery Nature of surgery Urgency of surgeryUrgency of surgery Level of glycemic control Level of glycemic control
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Factors Adversely Affecting Diabetic Control Peri-operatively
AnxietyAnxiety StarvationStarvation Anaesthetic drugsAnaesthetic drugs InfectionInfection Metabolic response to traumaMetabolic response to trauma Diseases underlying need for Diseases underlying need for
surgerysurgery Other drugs e.g. steroidsOther drugs e.g. steroids
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~2x~2x
Mort
ality
Rate
(%
) M
ort
ality
Rate
(%
)
Mean Glucose Value (mg/dL)Mean Glucose Value (mg/dL)
N=1826 ICU patients.Krinsley JS. Mayo Clin Proc. 2003;78:1471-1478.
0
5
10
15
20
25
30
35
40
45
80-99100-119120-139140-159160-179180-199200-249250-299>3000
5
10
15
20
25
30
35
40
45
0
5
10
15
20
25
30
35
40
45
Hyperglycemia & MortalityHyperglycemia & Mortalityin the Medical Intensive Care Unit in the Medical Intensive Care Unit
~4x~4x~3x~3x
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CABG, coronary artery bypass graft.Furnary AP et al. J Thorac Cardiovasc Surg. 2003;125:1007-1021.
Cardiac-related mortality
Noncardiac-related mortality
Post-CABGPost-CABG
0
2
4
6
8
10
12
14
16
<150 150–175 175–200 200–225 225–250 >250
Average Postoperative Glucose (mg/dL)Average Postoperative Glucose (mg/dL)
Mort
ality
%M
ort
ality
%Mortality Increases With IncreasesMortality Increases With Increases
in Average BG Levelsin Average BG Levels
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Mortality Risk Is Greater in Hyperglycemic Patients Without
History of Diabetes
111-111-145145
146-199146-199
200-300200-300
>300>300
Mean
BG
(m
g/d
L)
Mean
BG
(m
g/d
L)
Odds RatioOdds Ratio Odds RatioOdds Ratio
History Diabetes, History Diabetes, N= 62,868N= 62,868
No History Diabetes, No History Diabetes, N=152,910N=152,910
Falciglia M, et al. Crit Care Med. 2009;37:3001-3009.
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Hyperglycemia Is Linked to Mortality Regardless of Diabetes
Status
* ≥200 mg/dL.Rady MY, et al. Mayo Clin Proc. 2005;80:1558-1567.Ainla MIT, et al. Diabet Med. 2005;22:1321-1325.
*
*
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Mortality in Inpatients With
“New Hyperglycemia””
Umpierrez GE, et al. J Clin Endocrinol Metab. 2002;87:978-982.
In-h
osp
ital M
ort
ality
Rate
(%
)In
-hosp
ital M
ort
ality
Rate
(%
)
Newly Discovered
Hyperglycemia
Newly Discovered
Hyperglycemia
Patients With History of Diabetes
Patients With History of Diabetes
Patients With
Normoglycemia
Patients With
Normoglycemia
P <.01P <.01
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Study Setting Population Clinical Outcome
Furnary, 1999 ICUDM undergoing open
heart surgery65% infection
Furnary, 2003 ICU DM undergoing CABG 57% mortality
Krinsley, 2004Medical/
surgical ICU Mixed, no Cardiac 29% mortality
Malmberg, 1995 CCU Mixed28% mortality
After 1 year
Van den Berghe, 2001*
Surgical ICU Mixed, with CABG 42% mortality
Lazar, 2004 OR and ICU CABG and DM60% A Fib post op
survival 2 year
Kitabchi AE, et al. Metabolism. 2008;57:116-120.
Benefits of Tight Glycemic Control: Observational Studies and Early
Intervention Trials
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Glucose Control With IV Insulin Lowers Mortality Risk After Cardiac Surgery
10
8
6
4
0
Mort
ality
(%
)M
ort
ality
(%
)
87 88 89 90 91 92 93 94 98 99 00
YearYear
Patients with diabetes
Patients without diabetes
2
95 96 97 01
IV Insulin Protocol
Furnary AP, et al. Ann Thorac Surg. 1999;67:352-362.
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Inzucchi SE. NEJM 2006;355;1903
Hyperglycemia & Acute Ilness
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Hyperglycemia
Increases risks of
postoperative infections and
delirium
Prolonged hospital stay,
resource utilization
Increased renal
dysfunction and renal allograft
rejection in transplant
Adverse Effects of Hyperglycemia
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Metabolic Responses to Surgery HormonalHormonal
– Secretion of stress Secretion of stress hormoneshormones
CortisolCortisol CatecholaminesCatecholamines GlucagonGlucagon Growth HormoneGrowth Hormone CytokinesCytokines
– Relative decrease Relative decrease in insulin secretionin insulin secretion
– Peripheral insulin Peripheral insulin resistanceresistance
MetabolicMetabolic– Increased Increased
gluconeogenesis gluconeogenesis and and glycogenolysisglycogenolysis
– HyperglycaemiaHyperglycaemia– LipolysisLipolysis– Protein breakdownProtein breakdown
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Patients with diabetes deserve Patients with diabetes deserve
attentionattention
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The Data for SurgeryThe Data for Surgery
Blood Glucose Level > 180 mg/dL(Hyperglycemia)
Increased Risk of Postoperative Complications
Importance of Perioperative Glycemic Control in General Surgery; Ann Surg, 2013:257Perioperative management of diabetes: Translating evidence into practice; CCJM, 2009
Blood Glucose Level < 70 mg/dL(Hypoglycemia)
Increased Risk of Mortality
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Pre-operative Assessment
Most important step in the management of the Most important step in the management of the diabetic patientdiabetic patient
Involves a thorough history & physical examination Involves a thorough history & physical examination Review prior anaesthetic records to determine Review prior anaesthetic records to determine
whether there were any difficulties with intubation whether there were any difficulties with intubation or anaesthetics or anaesthetics
Lab investigationsLab investigations
– blood glucoseblood glucose - K+- K+
– BUNBUN - creatinine- creatinine
– ketonesketones - proteinuria- proteinuria
– HbA1c (to assess how well controlled diabetes HbA1c (to assess how well controlled diabetes is)is)
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Pre-Operative Management
Admit as early as possible prior to surgeryAdmit as early as possible prior to surgery Avoid long-acting glucose lowering agentsAvoid long-acting glucose lowering agents
– chlorpropamidechlorpropamide –glibenclamide–glibenclamide– ultralente insulinsultralente insulins
Avoid metforminAvoid metformin Closely monitor blood glucose levelsClosely monitor blood glucose levels
– 2 hourly for Type 12 hourly for Type 1
– 4 hourly for type 2 4 hourly for type 2 Test urine every 8 hours for ketones Test urine every 8 hours for ketones Place first on morning operating list if possiblePlace first on morning operating list if possible Aim for a blood glucose of 5-10mmol/LAim for a blood glucose of 5-10mmol/L
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CONTINUECONTINUE pre-hospital diabetes regimen if pre-hospital diabetes regimen if
appropriate, otherwise …appropriate, otherwise …
USEUSE insulininsulin as the treatment of choice as the treatment of choice
DO NOT DO NOT use sliding scale insulin aloneuse sliding scale insulin alone
DODO use use BASAL + BOLUS + CORRECTION BASAL + BOLUS + CORRECTION
insulin regimeninsulin regimen
AVOID AVOID hypoglycemiahypoglycemia
In-hospital Management In-hospital Management ChecklistChecklist
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Clinical GuidelinesClinical Guidelines
“Patients need to have a blood glucose checked upon admission, & then every 1-2
hours while fasting”
“For blood glucose levels ≤ 70 mg/dL, institute must have the Treatment for
Hypoglycemia Protocol”
“Postoperatively, check blood glucose level upon arrival to unit, before meals, &
at bedtime or four times per day (if fasting)”
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Create System to Support Clinical Create System to Support Clinical GuidelinesGuidelines
• How are we going to make this How are we going to make this happen?happen?
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Mix of standard & non-standard Mix of standard & non-standard processesprocesses
Standard processes across specialties
Non-standard processes & resources, defined by each specialty
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Does each area have the capacity & Does each area have the capacity & resources to check a blood glucose every resources to check a blood glucose every
2 hours on every diabetic patient?2 hours on every diabetic patient?
Challe
ng
eS
olu
tion
Lack Capacity
use glucometer
meters
Trained nursing
assistants to use meters
Lack Capacity
OR Lab could not support 2 hour testsOR Lab changed staffing
model using sweep
method
Lack Capacity
Lab staff on-call for as
needed tests
Ns trained to use meters
No change required
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In the absence of routine In the absence of routine
insulin, sliding scale insulin insulin, sliding scale insulin
regimen (bolus insulin on a regimen (bolus insulin on a
prn basis) is purely prn basis) is purely
reactive rather than reactive rather than
proactiveproactive and allows for and allows for
hyperglycemia to occur hyperglycemia to occur
before responding before responding
BG (mmol/L) Bolus insulin (U)
<4 Call MD
4.1 – 10.0 0
10.1 – 13.0 2
13.1 – 16.0 4
16.1 – 19.0 6
>19.0 Call MD
Queale WS. et al. Arch Int Med 1997;157
Sliding Scale Alone is Inefficient
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4.0
10.0
Breakfast Lunch Dinner Bedtime
BG (mmol/L) Bolus insulin (U)
< 4 Call MD
4.1 – 10.0 0
10.1 – 13.0 2
13.1 – 16.0 4
16.1 – 19.0 6
> 19.0 Call MD
6.0
Bolus insulin QID
14.0
6.0
16.5
3.0
Sliding Scale alone
What do you do?
What do you do?
What do you do?
What do you do?
+4 U
0 U 0 U
+6 U
QID: four times daily; SSI: sliding-scale insulin; BG: blood glucose
Sliding Scale Insulin Alone Results in Variable Glucose Control
BG (mmol/L)
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**
**
** **
* P<0.001.Umpierrez GE, et al. Diabetes Care. 2007;30:2181-2186.
Mean BG Before Meals and at Bedtime During Basal-Bolus and SSI Therapy in
General Surgery Patients
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Use BASAL + BOLUS + CORRECTION
In-hospital circumstances In-hospital circumstances may warrant temporarily may warrant temporarily
holdingholding other other antihyperglycemic antihyperglycemic
medications (medications (eg. eg. renal or renal or hepatic impairment)hepatic impairment)
Insulin = treatment of choiceInsulin = treatment of choice
BASAL + BASAL + BOLUS + BOLUS + CORRECTION CORRECTION
Insu
lin
BOLUS + CORRECTION
BASAL
Breakfast
Lunch
Dinner
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BASAL + BOLUS + CORRECTION Results in Smoother Glycemic Control
4.0
10.0
Breakfast Lunch Dinner Bedtime
BG (mmol/L) Bolus insulin (U)
< 4 Call MD
4.1 – 10.0 0
10.1 – 13.0 2
13.1 – 16.0 4
16.1 – 19.0 6
> 19.0 Call MD
6.0
12.0
6.0
Correctional Insulin AC meals
What do you do?
What do you do?
What do you
do?
6+2 U
6+0 U
6U 6U
What do you do?6+0 U
6.0
ROUTINE Bolus insulin
Basal insuli
n
6U
18 U
Routine Basal
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Create Clinical Guidelines Create Clinical Guidelines
““What do we need to do?”What do we need to do?”
Goal for Clinical GuidelinesGoal for Clinical Guidelines::
Establish a framework for the development of Establish a framework for the development of
processes & protocols to processes & protocols to maintain a random maintain a random
blood glucose (BG) < 180 mg/dL without blood glucose (BG) < 180 mg/dL without
increasing rates of symptomatic hypoglycemiaincreasing rates of symptomatic hypoglycemia, ,
or blood glucose levels <70 mg/dL in the adult or blood glucose levels <70 mg/dL in the adult
diabetic surgical patientdiabetic surgical patient
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Kavanagh BP, McCowen KC. N Engl J Med. 2010;363:2540-2546.
Year Organization Patient PopulationTreatment Threshold
Target Glucose
LevelDefinition of
Hypoglycemia
Updated since
NICE-SUGAR Trial, 2009
2009 American Association of Clinical Endocrinologists and American Diabetes Association
ICU patients 180 140-180 <70 Yes
2009 Surviving Sepsis Campaign ICU patients 180 150 Not stated Yes
2009 Institute for Healthcare Improvement
ICU patients 180 <180 <40 Yes
2008 American Heart Association ICU patients with acute coronary syndromes
180 90-140 Not stated No
2007 European Society of Cardiology and European Association for the Study of Diabetes
ICU patients with cardiac disorders
Not stated “Strict” Not stated No
Guidelines From Professional Guidelines From Professional Organizations on the Management of Organizations on the Management of Glucose Levels in the ICUGlucose Levels in the ICU
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Guidelines From Professional Guidelines From Professional Organizations on the Management of Organizations on the Management of
Glucose Levels in Noncritically Ill PatientsGlucose Levels in Noncritically Ill Patients
Year Organization Patient Population
Treatment Threshold
Target Definition of Hypoglycemia
Updated since NICE-SUGAR Trial, 2009
2009 AACE and ADA Consensus Statement
Non-critically ill patients
180 mg/dL
Premeal <140 mg/dL
<70 mg/dL(reassess treatment if <100 mg/dL)
Yes
2012 Endocrine Society Clinical Practice Guideline
Non-critically ill patients
180 mg/dL
Premeal <140 mg/dL
(reassess treatment if <100 mg/dL)
Yes
Moghissi ES, et al. Endocr Pract. 2009;15:353-369.Umpierrez GE, et al. J Clin Endocrinol Metabol. 2012;97:16-38.
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Moghissi ES, et al. Endocr Pract. 2009;15:353-369.
AACE/ADA Recommended Target AACE/ADA Recommended Target Glucose Levels in ICU PatientsGlucose Levels in ICU Patients
ICU setting:ICU setting:– Starting threshold no higher than 180 mg/dLStarting threshold no higher than 180 mg/dL– Once IV insulin is started, the glucose level should be Once IV insulin is started, the glucose level should be
maintained between 140 and 180 mg/dL maintained between 140 and 180 mg/dL – Lower glucose targets (110-140 mg/dL) may be Lower glucose targets (110-140 mg/dL) may be
appropriate in selected patientsappropriate in selected patients– Targets <110 mg/dL or >180 mg/dL are not Targets <110 mg/dL or >180 mg/dL are not
recommendedrecommended
Recommended
140-180
Acceptable110-140
Not recommended
<110
Not recommended
>180
3535
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AACE/ADA Recommended Target AACE/ADA Recommended Target Glucose Levels in Non-ICU PatientsGlucose Levels in Non-ICU Patients
Non–ICU setting:Non–ICU setting:– Premeal glucose targets <140 mg/dL Premeal glucose targets <140 mg/dL – Random BG <180 mg/dLRandom BG <180 mg/dL– To avoid hypoglycemia, reassess insulin regimen if To avoid hypoglycemia, reassess insulin regimen if
BG levels fall below 100 mg/dLBG levels fall below 100 mg/dL– Occasional patients may be maintained with a Occasional patients may be maintained with a
glucose range below and/or above these cut-points glucose range below and/or above these cut-points
Hypoglycemia = BG <70 mg/dLSevere hypoglycemia = BG <40 mg/dL
Moghissi ES, et al. Endocr Pract. 2009;15:353-369. 3636
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Endocrine Society Endocrine Society Recommended Recommended Target Glucose Levels in Non-ICU Target Glucose Levels in Non-ICU
PatientsPatients
Blood glucose targets for the majority of patientsBlood glucose targets for the majority of patients
– Premeal: <140 mg/dLPremeal: <140 mg/dL
– Random: <180 mg/dLRandom: <180 mg/dL
Glycemic targets should be modified according to clinical statusGlycemic targets should be modified according to clinical status
– For patients who achieve and maintain glycemic control without For patients who achieve and maintain glycemic control without
hypoglycemia, a lower target range may be reasonablehypoglycemia, a lower target range may be reasonable
– For patients with terminal illness and/or with limited life expectancy or at For patients with terminal illness and/or with limited life expectancy or at
high risk for hypoglycemia, a higher target range (BG <200 mg/dl) may be high risk for hypoglycemia, a higher target range (BG <200 mg/dl) may be
reasonablereasonable
To avoid hypoglycemia, reassess and modify diabetes therapy when To avoid hypoglycemia, reassess and modify diabetes therapy when
BG is ≤100 mg/dLBG is ≤100 mg/dL
Modification of glucose-lowering treatment is usually necessary Modification of glucose-lowering treatment is usually necessary
when BG values are <70 mg/dLwhen BG values are <70 mg/dLUmpierrez GE, et al. J Clin Endocrinol Metabol. 2012;97:16-38. 3737
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What are confounding factors in a diabetic for What are confounding factors in a diabetic for
emergency surgery?emergency surgery?
Do we have to wait for the DKA to settle before Do we have to wait for the DKA to settle before
taking up the patient?taking up the patient?
What are the indicators for going ahead with What are the indicators for going ahead with
surgery?surgery?
At what pH do we need sodabicarb correction; At what pH do we need sodabicarb correction;
what before that?what before that?
Role of insulin bolusRole of insulin bolus
Any alteration in monitoring?Any alteration in monitoring?
When to start KWhen to start K++, when glucose?, when glucose?
DM with uncontrolled BS for semi-em tomorrow; DM with uncontrolled BS for semi-em tomorrow;
are you game? If yes, how; if no, why not?are you game? If yes, how; if no, why not?
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Confounding factors in a Confounding factors in a diabetic for emergency diabetic for emergency surgerysurgery
– Usually associated withUsually associated with infectious processinfectious process pronounced hyperglycemia, pronounced hyperglycemia,
dehydration and hypovolemiadehydration and hypovolemia metabolic decompensationmetabolic decompensation ± DKA± DKA
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– Start aggressive treatment of DKAStart aggressive treatment of DKA complete resolution is usually not possible without complete resolution is usually not possible without
correction of the surgical problemcorrection of the surgical problem volume resuscitation (remember losses due to volume resuscitation (remember losses due to
precipitating cause)precipitating cause) partial correction of hyperglycemia, metabolic partial correction of hyperglycemia, metabolic
acidosis and ketosis acidosis and ketosis Consider bicarbonate if pH<6.9/7.0; bicarb conc. < Consider bicarbonate if pH<6.9/7.0; bicarb conc. <
10 mEq/L; hypotension unresponsive to IV fluids)10 mEq/L; hypotension unresponsive to IV fluids) insulin insulin bolusbolus & infusion as in the non surgical & infusion as in the non surgical
patient in DKApatient in DKA re-established urine output re-established urine output potassium supplementationpotassium supplementation phosphate supplementationphosphate supplementation start treatment of infectious process, if presentstart treatment of infectious process, if present
– Aim: Aim: definite trend towards metabolic definite trend towards metabolic improvementimprovement
– Monitor more oftenMonitor more often
Till thenTill then
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Intra-op management?Intra-op management?
Post-op management?Post-op management?
What do persistent ketosis What do persistent ketosis with S. bicarb < 20 mEq/L & with S. bicarb < 20 mEq/L & normal BG indicate?normal BG indicate?
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– Continue management of DKAContinue management of DKA
– Monitor more oftenMonitor more often
– There will usually be a rapid decrease There will usually be a rapid decrease in insulin requirements after surgery in insulin requirements after surgery metabolic control regainedmetabolic control regained need for careful and frequent monitoring need for careful and frequent monitoring
of BS and metabolic parametersof BS and metabolic parameters
– Persistent ketosis with S. bicarb < 20 Persistent ketosis with S. bicarb < 20 mEq/L & normal BG indicate need for mEq/L & normal BG indicate need for intracellular glucose and insulin for intracellular glucose and insulin for reversal of lipolysisreversal of lipolysis
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Most of the poorly controlled Most of the poorly controlled diabetics can be controlled in diabetics can be controlled in about 12 h about 12 h – Start insulin infusionStart insulin infusion
– Check blood gases and capillary Check blood gases and capillary glucose hourlyglucose hourly
– Give sufficient glucose and potassium Give sufficient glucose and potassium
DM with uncontrolled BS DM with uncontrolled BS for semi-em tomorrowfor semi-em tomorrow
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Diabetic ketoacidosis (DKA)Diabetic ketoacidosis (DKA) vs. vs. Hyperglycemic, hyperosmolar non Hyperglycemic, hyperosmolar non ketotic state (HHNS)ketotic state (HHNS)
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Diagnosis of DKA: pHa < 7.3, HCO3 < 15 mmol.l-
1, BG > 250 mg.dl-1 Moderate
ketonemia and ketonuria
HHNS: pHa > 7.3 HCO3 > 20mmol.l-1
BG > 28mmol.l-1 (500 mg.dl-1)
Absent/minimal serum ketones
Urinary ketones -/minimal
Osmolality > 330 mOsm.kg-1
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Ringer’s lactate?Ringer’s lactate?Bank blood?Bank blood?
Fluid and volume replacementFluid and volume replacement Lactate and is a gluconeogenic substrateLactate and is a gluconeogenic substrate
Ringer’s lactate = 28 meq/L Ringer’s lactate = 28 meq/L
Bank blood = variable amounts (anaerobic metabolism Bank blood = variable amounts (anaerobic metabolism
during storage) during storage)
Hepatic conversion to glucose Hepatic conversion to glucose aggravation of stress- aggravation of stress-
induced hyperglycemiainduced hyperglycemia
– Ringer’s lactate/Blood are NOT Ringer’s lactate/Blood are NOT
contraindicated contraindicated but but inappropriateinappropriate as these can as these can
confound the calculation of glucose load and insulin confound the calculation of glucose load and insulin
requirements requirements somewhatsomewhat
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CONTINUECONTINUE pre-hospital diabetes regimen if pre-hospital diabetes regimen if
appropriate, otherwise …appropriate, otherwise …
USEUSE insulininsulin as the treatment of choice as the treatment of choice
DO NOT DO NOT use sliding scale insulin aloneuse sliding scale insulin alone
DODO use use BASAL + BOLUS + CORRECTION BASAL + BOLUS + CORRECTION
insulin regimeninsulin regimen
AVOID AVOID hypoglycemiahypoglycemia
Take Home Message Take Home Message In-hospital Management In-hospital Management
ChecklistChecklist
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Take Home Message Take Home Message
In hospitalized patients In hospitalized patients
Proactive approach that includes Proactive approach that includes
basal, bolus, &correctionbasal, bolus, &correction
(supplemental) insulin(supplemental) insulin
sliding-scalesliding-scale insulin alone is not enough insulin alone is not enough
Uses Uses only short- or rapid-acting insulin only short- or rapid-acting insulin
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1.1. NNon critically ill patients on critically ill patients
pre-meal BG targets should be pre-meal BG targets should be 5.0 to 8.0 5.0 to 8.0
mmol/L mmol/L
Random BG values Random BG values <10.0 mmol/L<10.0 mmol/L
2. M2. Medical/surgical critically ill edical/surgical critically ill 8.0-10.0 8.0-10.0
mmol/L mmol/L
2013
2013
Take Home Message Recommendations 1 & 2
A continuous IV insulin infusioninfusion
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3. I3. Intraoperativentraoperative Glycemic levels between Glycemic levels between 5.5-10.05.5-10.0 mmol/L mmol/L for for
CABGCABG
A continuous A continuous IV IV insulin infusion protocol insulin infusion protocol administered by administered by
trained staff, trained staff, should be usedshould be used
4. Perioperative4. Perioperative glycemic glycemic 5.0-10.0 mmol/L 5.0-10.0 mmol/L for other surgical for other surgical
situationssituations
Appropriate protocol & trained staff to ensure safe & effective Appropriate protocol & trained staff to ensure safe & effective
implementation of therapy & to minimize the likelihood of implementation of therapy & to minimize the likelihood of
hypoglycemia hypoglycemia
2013
Take Home Message Take Home Message Recommendations 3 and 4Recommendations 3 and 4
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5. 5. In hospitalized patients, hypoglycemia should In hospitalized patients, hypoglycemia should be avoided: be avoided:
– ProtocolsProtocols for hypoglycemia for hypoglycemia avoidanceavoidance
– RecognitionRecognition and and managementmanagement should be implemented should be implemented with with nurse nurse
– initiated treatmentinitiated treatment
– Glucagon for severe hypoglycemia when IV access is not Glucagon for severe hypoglycemia when IV access is not readily available readily available
– Patients at risk of hypoglycemia should have Patients at risk of hypoglycemia should have ready ready accessaccess to source of glucose (oral or IV) at all times to source of glucose (oral or IV) at all times
– particularly when NPO or during diagnostic procedures particularly when NPO or during diagnostic procedures
2013
Take Home Message Take Home Message Recommendation 5Recommendation 5
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Patient Type Glucose Target (mmol/L)
Therapy of choice
Non-critically ill Fasting 5-8
Random <10
Pre-hospital regimen OR basal-bolus-correction
Critically ill 8-10 IV insulin infusion
CABG intraop 5.5-10 IV insulin infusion
Other periop 5-10 As appropriate
CABG = coronary artery bypass graft; IV = intravenous; Intraop = intraoperative; periop = perioperative
In-hospital Glycemic Targets
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Thank YouThank You