perioperative diabetes mellitus management

PERIOPERATIVE MANAGEMENT OF DIABETES MELLITUS

SPEAKER Dr. DHARMRAJ SINGH

MODERATORDr. SHASHI PRAKASH

INTRODUCTION

Patients with diabetes have higher incidence of morbidity and mortality.

Poor peri-operative glycaemic control increases the risk of adverse outcomes.

Treatment of post-operative hyperglycaemia reduces the risk of adverse outcomes.

CRITERIA FOR DIAGNOSIS OF DIABETES

1. Symtoms of diabetes plus random plasma glucose level >200 mg/dL

(11.1 mmol/L)

2. Hemoglobin A1C ≥ 6.5 %

3. Fasting plasma glucose level ≥ 126 mg/dL (7.0 mmol/L)

4. Two-hour plasma glucose level ≥ 200 mg/dL (11.1 mmol/L)

American Diabetes Association

METABOLIC SYNDROME

At least three of the following Fasting plasma glucose ≥ 110 mg/dl

Abdominal obesity (waist girth > 40 [in men], 35 [in women])

Serum triglycerides ≥ 150mg/dl

Serum HDL cholesterol < 40 mg/dl (men), <50 (women)

BP ≥ 130/85 mm Hg

Insulin-resistant syndrome is a constellation of clinical & biochemical characteristics frequently seen in pt with or at risk of type 2 diabetes.

THE METABOLIC RESPONSE TO SURGERY AND THE EFFECT OF DIABETES

Metabolic effects of starvation:

1. Period of starvation induces a catabolic state.

2. It will stimulate secretion of counter-regulatory hormones .

3. It can be attenuated in patients with diabetes by infusion of insulin and glucose (approximately 180g/day).

Metabolic effects of major surgery.

It causes neuroendocrine stress response with release of counter- regulatory hormones (epinephrine, glucagon, cortisol and growth hormone) and of inflammatory cytokines IL-6 and tumor necrosis factor-alpha.

CONTD…

Hypoglycaemia – exacerbate the catabolic effect of surgery

These neuro hormonal changes result in metabolic

abnormalities including

Increased insulin resistance.

decreased peripheral glucose utilization.

impaired insulin secretion.

increased lipolysis .

protein catabolism, leading to

hyperglycemia and even ketosis in some cases…

WHY SPECIAL CONCERNS ?

Hypo and hyperglycemia.

Multiple co-morbidities including microvascular and macrovascular complications.

Complex polypharmacy , including misuse of Insulin.

Inappropriate use of intravenous insulin infusion.

Management errors when converting from the intravenous insulin infusion to usual medication.

Peri-operative infection.

PRE-OPERATIVE EVALUATION

Determine the type of diabetes and its management.

Ensure that the patient’s diabetes is well controlled.

Review of medications.

Ensure that the patient is capable of managing their diabetes after discharge from hospital.

Consider the presence of complications of diabetes that might be adversely affected by or that might adversely impact upon the outcome of the proposed procedure.

Identify high-risk patients requiring critical care

management.

PRE-0PERATIVE EVALUATIONTo Assess History/Examination Investigation

1.Blood Sugar Control

Hypo/Hyperglycemic episodes,Hospitalization,Medical compliance

BS- F & PPHbA1C

2. Nephropathy H/O- HTN, Swelling over body, Recurrent UTI.

Urine R/M (to exclude Albuminuria and UTI)RFT

3.Cardiac Status H/O- Angina/ MI , Swelling of feet,Exercise intolerance

ECG, CXR, ECHO,TMT(ECG-less predictive )

4. PVD H/O- Intermittent Claudication, Blanching of feet,Non healing ulcer

CONTD..

To Assess History/Examination Investigation

5. Retinopathy H/O-Visual disturbances↑ power of lenses

Fundus Examination

6. ANSEarly satiety, abdominal distension, Anhidrosis, Impotence, Orthostatic Syncope

Postural change in BP, HR variability with exercise, tachycardia response to atropine

7. Metabolic & Electrolyte

H/O- Starvation, InfectionSign of DKA,

ABG, Urinary Ketone,Sr. Electrolyte

8. Airway Scleroderma of DiabetesStiff Joint Syndrome(Prayer sign, Palm Print test)

X-ray cervical spine AP & Lateral

CONTD….

Prayer Sign:

Patient is unable to approximate the palmar surface of phalangeal joints despite of maximal effort.

Palm Print Test:Degree of inter-phalyngeal joint involvement can also be assessedby scoring the ink impression made by the palm of dominanthand.

CLINICAL SIGNS OF DIABETIC AUTONOMIC NEUROPATHY

Hypertension

Painless MI

Orthostatic hypotension

Lack of HR variability

Reduced HR response to atropine & propanolol

Resting tachycardia

Early satiety

Nerugenic bladder

Lack of sweating

Impotence

TESTS FOR DIABETIC AUTONOMIC NEUROPATHY (DAN)

Early stage: abnormality of HR response during deep breathing

Intermediate stage: abnormality of Valsalva response

Late stage: presence of postural hypotension

The test are valid marker of DAN if following factors ruled out.

1. End organ failure

2. Concomitant illness

3. Drungs: antidepressents, antihistamines, diuretics, vasodilators, sympathatic blockers, vagolytics.

TEST FOR AUTONOMIC NEUROPATHY

Heart rate variability (HRV) in response to:

Deep breathing

Standing

Valsalva maneuver

BP response to:

1.Standing or passive tilting

2.Sustained hand grip

3.Valsalva maneuver

GENERAL PRINCIPLES

Diabetes should be well controlled prior to elective surgery.

Avoid insulin deficiency, and anticipate increased insulin requirements.

The patient’s diabetes care provider should be involved in the management of their patient’s diabetes peri-operatively.

Patients must be given clear written instructions concerning the

management of their diabetes both pre- and post-operatively (including medication adjustments) prior to surgery.

CONTD…

Patients must not drive themselves to the hospital on the day of the procedure.

Patients with diabetes should be on the morning list, preferably first on the list.

These guidelines may need to be individually modified depending on the patient’s circumstance.

Patients should be well hydrated before the procedure.

GOALSTo maintain glycaemic control.

To prevent further deterioration of pre-existing end organ damage and minimise the metabolic consequence of starvation and surgical stress.

To shift patient soon on pre-operative glycaemic control drugs and prevention of PONV.

To prevent complication.

Greater concern for aseptic precaution.

Postoperative pain management.

GLYCEMIC CONTROL

Postpone elective surgery if possible if glycaemic control is poor

(HbA1c ≥ 9%).

For major surgery, if serum glucose is >270 mg/dl preoperatively, surgery should be delayed while rapid control is achieved with IV insulin.

If serum glucose is >400 mg/dl , the surgery should pe postponed and metabolic state restabilized.

CONTD…

BGL should be kept between 5 – 10mmol/l (90-180mg/dl) during the perioperative period .

For critically ill patients who require admission to the intensive care unit post-operatively, a “tighter” BGL target (e.g 4.4-6.1 mmol/L) may not convey any greater benefit.

Hypoglycemia must be avoided.

All patients with diabetes treated with insulin should be managed in the same way, irrespective of whether they have type 1 or type 2 diabetes mellitus.

CONTD…

Insulin management dependent on Pre-op glycemic controlInsulin regimenMagnitude of surgeryTiming and duration of surgeryResumption of patients usual diet.

Minor surgery is defined as all day-only procedures, while major surgery includes all procedures that require at least an overnight admission*

PERIOPERATIVE DIABETES MANAGEMENT GUIDELINES-AUSTRALIAN DIABETES SOCIETY MAY 2011

PATIENTS WHO REQUIRE INSULIN THERAPY

This group includes patients with type 1 diabetes or patients with type 2 diabetes who require day time insulin injections.

Patients who take both evening and morning doses of insulin should take their usual dose of evening short-acting insulin, but reduce their intermediate- or long-acting dose by 20% the night before surgery.

On the morning of surgery, they should omit their short-acting insulin and reduce the intermediate- or long-acting dose by 50% (and take this only if the fasting glucose is >120 mg/dl)

Premixed insulin → reduce their evening dose prior surgery by 20% and hold insulin completely on the morning of procedure.

Some patients receiving insulin may also take oral AHG.

MAJOR SURGERY(MORNING LIST)

Maintain the usual insulin doses and diet the day before, and fast from midnight.

Omit usual morning insulin (and AHG).

Commence an insulin-glucose infusion prior to induction of anaesthesia (or by 1000hrs at the latest).

Measure BGL at least hourly during the intra-operative period.

Continue the insulin-glucose infusion for at least 24 hours post-operatively and until the patient is capable of resuming an adequate oral intake

*PERIOPERATIVE DIABETES MANAGEMENT GUIDELINES-AUSTRALIAN DIABETES SOCIETY MAY 2012

MAJOR SURGERY(AFTERNOON LIST)

Give a reduced dose of insulin before early breakfast in the morning.(reduced bolus insulin plus 1/2 day time dose as intermediate/long acting insulin)

Patients should arrive at the facility by 0900hrs and BGLs should be monitored closely in the pre-operative ward.

Commence an insulin-glucose infusion before induction of anaesthesia.


MINOR SURGERY MORNING LIST

Delay the usual morning dose of insulin provided that the procedure is completed and the patient is ready to eat by 1000hrs. The patient can then have a late breakfast after the usual dose of insulin is given.

For later procedures, give a reduced dose of insulin in the morning in the form of intermediate or long-acting insulin if possible.

If the BGL remains elevated (>10mmol/l), an I-G infusion should be commenced.

AFTERNOON LIST

Pre-operative insulin adjustments similar to that for major surgery in the afternoon.

An insulin-glucose infusion may be necessary if pre-operative insulin adjustments result in hyperglycemia.

Overnight admission may be necessary for those with glycemic instability or who are unable to resume their usual diet before discharge

PATIENTS ON ORAL AHG MEDICATION (WITHOUT INSULIN)

Stop AHG medication on the day of surgery.

Restart AHG medication when patients are able to resume normal meals (except possibly metformin and thiazolidinediones following cardiac surgery).

Commence an I-G infusion if the BGL >10 mmol/L(180mg/dl); if surgery is prolonged and complicated; or if the patient is usually treated with more than one oral AHG agent.

Subcutaneous insulin may be required post-operatively


PATIENTS ON DIET ALONE

For patients whose diabetes is maintained on diet alone and who are well controlled (HbA1c < 6.5%), no specific therapy is required, but more frequent BGL monitoring during the peri-operative period is recommended. During the procedure, BGLs should be checked hourly.

BGL remains above 10 mmol/L (180mg/dl) in the pre- or peri-operative period, an I-G infusion should be commenced and continued until they resume eating.

If the patient does not become hyperglycemic following surgery, the patients BGL should be monitored every 4 – 6 hours until they ‟resume their usual meals.

Patients who are hyperglycemic peri- or post-operatively may require supplemental insulin and/or the initiation of specific AHG


THE POST-OPERATIVE PERIOD

Insulin-glucose infusions should be continued until the patients can resume an adequate diet.(or atleast 24 hrs)

I-G infusions should ideally be stopped after breakfast, and a dose of

subcutaneous insulin (or oral AHG) is given before breakfast.

Hyperglycemia detected post-operatively in patients not previously known to have diabetes should be managed as if diabetes was present, and the diagnosis of diabetes reconsidered once the patient has recovered from their surgery.

Diabetes medication requirements may be increased (or occasionally decreased) in the post-operative period, and frequent BGL monitoring is therefore essential.

Diabetes management expertise must be available for the post-operative management of glycemic instability.

SLIDING SCALE REGIMEN S/C

Glucose in mg/dl Regular Insulin S/C

150-200 2 unit

201-250 4 unit

251-300 6 unit

301-350 8 unit

≥350 10 unit

Blood sugar to be stabilised 2-3 days prior to surgery

Start GKI infusion @ 100-125 ml/ hr

Blood Sugar in mg/dlInfusion

(10%dextrose+insulin+K+)

≤90 10+5+10

90-180 10+10+10

180-360 10+15+10

≥360 10+20+10

ALBERTI’S OR GKI REGIMEN

TIGHT CONTROL REGIMEN

Target Blood Sugar is 80-110 mg/dl.

Indications: Pregnancy, CPB, Neurosurgery.

Advantages: Improve wound Healing,

Prevent wound infection,

Improve neurological outcome.

Night before surgery do preprandial glucose.

Start 5% Dextrose @ 50 ml/hr.

Dissolve 50 U of insulin in 250 ml of NS and start piggy back infusion.

Insulin infusion rate is adjusted by BG/150 U per hr and

BG/100 U per hr if pt is obese or on steroid or in sepsis.

RISK – HYPOGLYCEMIA

ARRANGEMENT OF INTRAVENOUS LINE FOR INFUSION OF REGULAR INSULIN

VELLORE REGIMEN

All patients had blood glucose measured at 6 am.

For those patients whose operation started in the morning (7:30 am), no glucose or insulin was given in the ward.

All other patients receive a glucose insulin infusion in the ward, if their blood glucose is more than 100 mg/dL.

Regular insulin 5 U in 500 mL of 5% dextrose in water solution (D5W) was started in the ward at 8 am @ 100 mL/hr until the time of operation.

VELLORE REGIMENBlood sugar (mg/dL) Treatment

<70 Stop insulin if on insulin. Rapid infusion of 100 mL of D5W, measure blood glucose after 15 min

71-100 Stop insulin, infuse D5W at 100mL/h

101-150 1U of insulin + 100 mL of D5W/h




>300 1U of insulin for every 1-50 mg more than 100 mg/dL + 100 ml of normal saline/h

VIARIABLE RATE INTRAVENOUS INSULIN INFUSION(VRIII)

Make up a 50 ml syringe with 50 units of soluble human insulin in 49.5mls of 0.9% sodium chloridesolution. This makes the concentration of insulin 1 unit per ml.

The substrate solution to be used alongside the VRIII should be selected from:

• 0.45% saline with 5% glucose and 0.15% KCl, or• 0.45% saline with 5% glucose and 0.3% KCl

The rate of fluid replacement must be set to deliver the hourly fluid requirements of the Individual.( volumetric infusion pump).

Delivery of the substrate solution and the VRIII must be via a single cannula with appropriate one-way and anti-siphon valves .

RATE OF INSULIN INFUSION

Bedside capillary glucose (mmol/L) Initial rate of insulin infusion (units/hour)

<4.0 0.5(0.0 if a long acting background insulin

has been continued )

4.1-7.0 1

7.1-9.0 2

9.1-11.0 3

11.1-14.0 4

14.1-17.0 5

17.1-20 6

>20 Seek diabetes term of medical advice

FLUID MANAGEMENT

Aims of fluid management:

• Provide glucose as substrate to prevent proteolysis, lipolysis and ketogenesis.

• Maintain blood glucose level between 6-10mmol/L where possible (acceptable range 4-12mmol/L).

• Optimise intravascular volume status.

• Maintain serum electrolytes within the normal ranges.

CONTD…

The daily requirement of the healthy adult is :

• 1.5-2.5 litres of water• 50-100 mmol of sodium,• 40-80 mmol of potassium,• 180g glucose is needed to prevent catabolism(particularly DM).• Diabetic patients may require magnesium, phosphate…..

FLUID MANAGEMENT FOR PATIENTS REQUIRING A VARIABLE RATE

INTRAVENOUS INSULIN INFUSION*

The substrate solution to be used alongside the VRIII should be based on serum electrolytes,measured daily and selected from:

0.45% saline with 5% glucose and 0.15% potassium chloride (KCl) OR

0.45% saline with 5% glucose and 0.3% KCl.

* Management of adults with diabetes undergoing surgery and elective procedures: improving standards- NHS(National institute for health and clinical excellence ) APRIL 2011

CONTD…

Very occasionally, the patient may develop hyponatremia without signs of fluid or salt overload, In such cases 0.45% saline is replaced by 0.9% saline with dextrose and potassium.

hypovolemia/hypotension – treat with crystalloids.

• 0.9% Normal saline• Hartman solution(Gluconeogenic since lactate/acetate) not

contraindicated in diabetic(Interfere with glycemic control )

•1) Management of adults with diabetes undergoing surgery and elective procedures: improving standards- NHS(National institute for health and clinical excellence ) APRIL 2011.•2) Guidelines for intravenous fluid therapy for adult surgical patients(GIFTASUP )MAR 2011.

FLUID MANAGEMENT FOR PATIENTS NOT REQUIRING A VARIABLE RATE

INTRAVENOUS INSULIN INFUSION

Aims of fluid management: • Provide intravenous fluid as required according to individual need until the

patient has recommenced oral intake

• Maintain serum electrolytes within the normal ranges

• Avoid hyperchloraemic metabolic acidosis.

Recommendations * • Hartmann’s solution should be used in preference to 0.9% saline.

• Glucose containing solutions should be avoided unless the blood glucose is low.

•1) Management of adults with diabetes undergoing surgery and elective procedures: improving standards- NHS(National institute for health and clinical excellence ) APRIL 2011.•2) Guidelines for intravenous fluid therapy for adult surgical patients(GIFTASUP)MAR 2011.

ANAESTHESIA AND DIABETES

PREOP FASTING Atleast 6 hrs for solid foods.

Patients with gastroparesis , 12 hrs may be needed. Such patients are given H2 receptor blocker(Ranitidine) and prokinetics (metoclopromide).

When fasting exceeds 8-10 hrs then insulin-glucose infusion has to be started to prevent catabolism.

Gastric emptying(1)- in DM patients(2)- after Metoclopromide(3)- normal person

CONCERNS…

DM affects oxygen transport by causing glucose binding to Hb.

DM is considered CAD equivalent.

Chronic kidney disease is asymptomatic in diabetic and usually advanced.

Autonomic dysfunction :

• Exagerated Hypotension• Risk of hypothermia• Sympathetic response are blunted• Silent MI

CONTD…

Inhibits intestinal motility, delayed gastric emtying.

Difficult Airway-

• restricted joint movement(atlanto-occipital)• obesity

Therapy related-

• Sulphonylureas - hypoglycemia• Metformin - lactic acidosis• Incretins & amylin - delays gastric emptyig , nausea

PHARMACOLOGY

Propofol – lipid loading lead to impaired metobolism in DM, decreased lipid clearance. Its of more concern when given in infusion.

Etomidate - decreases adrenal steroidogenesis decreased glycaemic response to surgery.

Ketamine- may cause significant hyperglycemia

Midazolam –(high doses/infusion) decreases ACTH & Cortisol decreased sympathoadrenal

stimulation decreased glycemic response to surgery.

Alpha-2 adrenergic agonist – decreases sympathetic outflow from hypothalamus, decreases ACTH. improves glycemic control.

CONTD…

REGIONAL ANAESTHESIA

ADVANTAGES

Regional anaesthesia blunts the increases in catecholamines ,cortisol, glucagon, and glucose.

Metabolic effects of anaesthetic agents avoided

An awake patient – hypoglycaemia readily detectable.

Decreased chance of Aspiration, PONV and Thromboembolism.

Rapid return to diet and Sc insulin/OHA

DISADVANTAGES

If autonomic neuropathy is present, profound hypotension may occur.

Infections and vascular complications may be increased (epidural abscesses are more common in diabetics)

Medicolegal concern of risk of nerve injuries and higher risk of ischaemic injury due to use of adrenaline with LA

GENERAL ANAESTHESIA

ADVANTAGES

• High dose opiate technique may be useful to block the entire sympathetic nervous system and the hypothalamic pituitary axis.

• Better control of blood pressure in patients with autonomic neuropathy.

DISADVANTAGES

May have difficult airway. (“Stiff-joint syndrome”)

Full stomach due to gastroparesis.Controlled ventilation is needed as

patients with autonomic neuropathy may have impaired ventilatory control.

Aggravated haemodynamic response to intubation.

It may masks the symptoms of hypoglycaemia

ANAESTHESIA & DM SPECIAL SITUATIONS

PREGNANCY

Pregnancy is a diabetogenic state. As pregnancy advances insulin resistance increases.

Hyperglycemia during pregnancy has both maternal and fetal complications & adverse outcome.

Challenges – Altered maternal physiology & disease associated with pregnancy.

Maternal hyperglycaemia : Increases the risk of neonatal jaundice.

The risk of neonatal brain damage, and

Fetal acidosis if the fetus becomes hypoxic

GDM-DIAGNOSIS

ADA-American diabetes association guidelines 2011

CONCERNS…

Need tighter control.

• Premeal- 60-90mg/dl.

1 hr pp - < 140mg/dl.

2 hr pp - < 120mg/dl.

More prone for hypoglycemia /hyperglycemia

DKA – usually occurs during 2nd/ 3rd trimester, even develops with low glucose value of 200mg/dl.

DIABETIC CRISIS

HYPERGLYCEMIC :

• DKA

• HYPEROSMOLAR NONKETOTIC COMA.

HYPOGLYCEMIC:

BG≥ 250 mg/dl

Acidosis-pH<7.3

Serum HCO3<15meq/l

Serum Ketone>7meq/l

Osmolarity-300-320

K+ ↑/ ↓

Urine may be positive for

ketone body.

↑ anion gap metabolic acidosis

↑ serum amylase

DKAEM

LAB VALUES IN DKA & HHS

DKA HHS

Glucose mmol/l (mg/dl) 13.9-33.3 (250-600) 33.3-66.6 (600-1200)

Na meq/l 125-135 135-145

K meq/l N to ↑ N

Mg N N

Cl N N

PO4 N to ↓ N

Creatinine µmol/l (mg/dl) Slightly ↑ Moderately ↑

Osmolarity (mOsm/ml) 300-320 330-380

Plasma ketones ++++ ±

Serum HCOӡ meq/l <15 meq/l N to slightly ↓

Arterial pH 6.8-7.3 >7.3

Arterial PCO2 mmHg 20-30 N

Anion gap meq/l ↑ N to slightly ↑

DKA - MANAGEMENT

Insulin replacement- 0.1U/kg bolus followed by 0.1U/kg/hr and if BG does not ↓ by 10%-repeat

the loading dose –if still no response –double the infusion dose in every 2 hr.

Fluids: 0.9% NS-1-2 ltr in 1st hr

0.45%NS-2-5 ml/kg/hr

0.45%NS - when the BG< 250 mg/dl

& 5%DS

Electrolyte: 20-30meq of K+/ hr after 2 hr of t/t

Replace phosphate when, <1mg/dl

HNKC- MANAGEMENT

Insulin replacement: Less insulin require as compared to DKA 15 U i.v bolus then 0.1 U/kg/

hr

Fluids: Reqirement is more than DKA

0.9% NS-2-3 ltr in 2-3 hr

0.45%NS-2-5 ml/kg/hr

0.45%NS - when the BG< 250 mg/dl

& 5%DS

Electrolyte: 20-30meq of K+/ hr concurrently

HYPOGLYCEMIA

Blood sugar < 50 mg/dl.

Symptoms due to Adrenergic excess and Neuroglycopenia.

Sweating, tachycardia/bradycardia , tremers, hypotension, dizziness, irritability, seizures, or coma.

Stop insulin & give dextrose 20-30 ml 50%dxtrose

Dextrose infusion

Glucagon (0.5-1.0 mg IM )

Octreotide(sulphonylurea)

DM & EMERGENCY SURGERY

Usually Infected

Usually Uncontrolled

Dehydrated

Metabolic decompensated

Increased resistance to insulin

More Chances of acute Hyperglycemic complication

EMERGENCY SURGERY

Little time for stabilisation of patients ,but if 2-3 hr available

• correction of fluid and electrolyte imbalance .• Correct hyperglycemia.(start I-G infusion if sugar > 180mg/dl)*• Treat acidosis.• Avoid hypoglycemia.

Surgery should not be delayed in an attempt to eliminate ketoacidosis completely if the underlying condition will lead to further metabolic deterioration.


CONTD…

If enough time is not available – correction of hydration status , electrolytes, acidosis, blood sugar should be started & should achieve an improving metabolic trend before starting anaesthesia.

Likelyhood of intra-op hypotension and arrhythmia is more particularly if pt has pre-op acidosis or hypokalemia.

Intra-op sugar to be monitored more frequently. Atleast hourly. LSCS – every 30 min.*


CHILDREN & ADOLESCENSE WITH DM

Diagnostic criteria same as adults.*

Minimise physiological & metabolic stress.

Maintain Euglycemia.

Hyperglycemia reflects the dehydration/hypovolemia,and not the adequacy of insulin therapy.

Sr.glucose > 300mg/dl, hyperglycemia inversely proportional to renal function.(higher the glucose lower the creatinine clearance) .

CONTD…

The magnitude of hyperglycemia proportional to the magnitude of dehydration.

So, only Rehydration decreases the blood sugar & not insulin.

So ,the insulin dose is determined by the magnitude of metabolic stress and acid-base status.

CONTD…

Aim for blood glucose levels between 5-10 mmol/l (90-180 mg/dl) during surgical procedures in children.

No solid food for at least 6 hours prior to surgery.

To minimise the risk of hypoglycaemia, children should receive a glucose infusion when fasting for more than 2 hours before a general anaesthesia.

At least 2 hours before surgery start an IV insulin infusion.

ISPAD-Management of childhood& adoloscence diabetes guidelines 2011

CONTD…

Monitor blood glucose hourly before surgery and every 30-60 minutes during the operation and until the child recovers from anaesthesia. Adjust IV insulin accordingly.

Do not stop the insulin infusion if BG <5–6 mmol/l (90 mg/dl) as this will cause rebound hyperglycemia. Reduce the rate of infusion.

MAINTENANCE FLUID GUIDE:

Glucose: 5 % glucose; 10 % if there is concern about hypoglycaemia. If BG is high

(>14 mmol/l, 250 mg/dl), normal saline without glucose and increase insulin supply but change to 0.45% saline with 5% dextrose when BG falls below 14 mmol/l (250 mg/dl).

Sodium:Give 0.45% saline with 5% glucose, carefully monitor electrolytes, and

change to 0.9% saline if plasma Na concentration is falling.

Potassium:Monitor electrolytes. After surgery, add potassium chloride 20 mmol to each litre of intravenous fluid.

.

T2 DM

ISPAD-Management of childhood& adoloscence diabetes guidelines 2011

For those individuals who have type 2 diabetes and are treated with insulin, follow the insulin guidelines as for elective surgery, depending on type of insulin regiment.

Patients on oral treatment:

Metformin : discontinue at least 24 hours before the procedure for elective surgery. In the event of emergency surgery and metformin I stopped < 24 hours before surgery, insure optimal hydration with IV fluids before ,during and after surgery.

Sulfonylureas or thiazolidinediones: stop for the day of surgery.

Monitor blood glucose hourly and if greater tha 10mmol/l (180mg/dl) treat with IV insulin, as for elective surgery, to normalise levels, or SC insulin if it is aminor procedure.

CONTROVERSIES IN DM

GLYCEMIC CONTROL

PATIENT POPULATION BLOOD GLUCOSE TARGET

RATIONALE

GENERAL MEDICAL/SURGICAL*

FBS – 90-126mg/dl

RANDOM- <200mg/dl

Decreased mortality , infection rates, shorter length of stay.

CARDIAC SURGERY* < 150mg/dl Decreased mortality , sternal wound infection rates.

CRITICALLY ILL # <150mg/dl Mortality, morbidity , length of stay.

ACUTE NEUROLOGICAL DISORDER ^^

80- 140mg/dl Lack of data , concensus on specific target, consensus for controlling hyperglycemia.

* AMERICAN DIABETIC ASSOCIATION# SOCIETY OF CRITICAL CARE MEDICINE^^ AMERICAN HEART ASSOCIATION/AMERICAN STROKE ASSOCIATION

CONTD…

Tighter control(80-110mg/dl): No added advantage, but more risk of

hypoglycemia.Higher glucose – adverse outcome.

In the virtual absence of clinical studies in general surgery, and considering the basic biological data on the harmful effects of hyperglycaemia, it is reasonable to recommend that blood glucose should be maintained in the range 6 to 10 mmol/L, if this can be achieved safely. A range from 4-12 mmol/L is acceptable. *

* 1.NICE GUIDELINES- APRIL 2011, * 2.AMERICAN DIABETIC ASSOCIATION. * 3.ISPAD-GUIDELINES 2011

FLUID & INSULIN

Since long time gold standard for controlling metabolic consequences of DM during surgery & starvation – glucose,insulin,potassium..

ALBERTI&THOMAS described GIK Regimen, but lactate containing solutions were not recommended since it exacerbate hyperglycemia.

Later many regimens were used, finally the most widely practised is the sliding scale regimen.

CONTD…

The terminology VARIABLE RATE INTRAVENOUS INSULIN INFUSION(VRIII) is preferred for sliding scale.

Advantages of VRIII :

• Flexibility for independent adjustment of fluid and insulin

• Accurate delivery of insulin via syringe driver

• Allows tight blood glucose control in the intra-operative starvation period.

FLUID MANAGEMENT(IN PATIENTS REQUIRING VRIII)

NPSA(National patient saftey agency)- recommends hypotonic fluids should be avoided. So 5% dextrose alone cantbe used.

0.45%saline,5%dextrose,potassium,though isotonic in vitro, its hypotonic in relation to plasma causes hyponatremia(particularly children)

Replacing with 0.9%saline cause sodium& chloride overload.

CONTD…

Since no randomised trails demonstrate superiority of any fluid, and until there are clincal studies to verify safest solution

• THE RECOMMENDATION IS• 0.45%SALINE,5%DEXTROSE&0.15%KCL as first choice.

FOR PATIENTS NOT REQ VRIII

• Ringers lactate/acetate, Hartmanns solution is used.• 0.9%saline hyperchloremic acidosis.


METFORMINMetformin does not worsen renal function. For major surgery, metformin should be stopped on the day of

surgery and recommenced(24hr P.O) if serum creatinine level does not deteriorate post-operatively.

Prolonged cessation of metformin will result in deterioration of glycaemic control and additional anti-hyperglycaemic treatment will be required.

Metformin need not be stopped for minor surgery. Metformin & I.V radiocontrast Creatinine : < 1.4mg/dl safe to continue(need monitoring) > 1.8mg/dl withdraw 48 hrs.


FUTURE STRATEGIES FOR TREATING DIABETES

Noninjectable routes of insulin administration (inhaled, oral, nasal, transdermal)

New injectable insulin formulation

Implantable insulin pump

Noninvasive continuous glucose sensors

New islet transplantation

Medication such as INGAP (islet neogenesis-associated protein) peptide, which may cause regrowth of normally functioning islet cells

SUMMARY

Ensure glycemic control.

Proper preop assessment

Hourly blood sugar monitoring.

Target blood sugar 5-10mmol (90-180mg/dl).

Substrate fluid 0.45%NS,5%Dextrose,0.15%KCL

0.9%NS / Hartmanns solution.

Avoid prolong fasting, start I-G Infusion.

VRIII – more flexible.

THANK YOUTHANK YOU

perioperative diabetes mellitus management

Education