preparing for medical procedures for patients with diabetes elizabeth duke gibbs rd, cde jennifer...
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Preparing for Medical Procedures for Patients with Diabetes
Elizabeth Duke Gibbs RD, CDE
Jennifer Shaver RN, CDE
Diabetes Education and Management Centre
Hotel Dieu Hospital
November 13, 2015
Objectives
Preoperative glycemic control
Non- insulin antihyperglycemics and fasting
Adjustments of insulin for fasting procedures/surgery
Diabetes issues related to medical procedures
SADMANS
The focus around surgery/medical procedures for those with diabetes is to avoid:
Hyperglycemia/Hypoglycemia
Diabetes Ketoacidosis (DKA)/Hyperosmolar Non-Ketotic State (HHNK)
Sepsis
Kadoi,Y. J Anesth. (2010) 24:739-747
Preoperative Glycemic Control
Numerous studies have shown that poor preoperative glycemic control is associated with adverse clinical outcomes including:
increased mortality, morbidity, delayed wound healing and postoperative infection.
(Kaczynski, et al (2010) 20: 411-413
Uncontrolled DM results in an increase of surgical and systemic complications
Length of hospital stay is higher among people with diabetes
Infections cause 2/3 of postoperative complications and is the principal cause of 20% of postoperative deaths among persons with diabetes.
Kadoi,Y. J Anesth. (2010) 24:739-747
(Kalezic, N. et al ACI/STRUCNI RAD (2011) 97-102
Non insulin Hyperglycemics and Fasting Type 2 DM
Important to assess the medications that the patient is on prior to surgery
May need to stop antihyperglycemics pre-op based on duration of action.
Class Agents Duration of action(h) Last dose should be taken no later than ..
Biguanide Metformin 12-24 Last meal prior to the onset of fasting
Incretins Byetta 4-6 Last meal prior to the onset of fasting
Victoza 24 24 h prior to the onset of fasting
Sulfonylureas Glyburide 16-24 24 h (occasionally 36 h) prior to the onset of fasting
DPP4 Januvia/Onglyza 24 24 h prior to the onset of fasting
Meglitinides Gluconorm 4-6 Last meal prior to the onset of fasting
Grajower,M (2011) Diabetes Metab Res Rev (27): 413-418
If a patient's glycemic control is not at target despite being on non-insulin antihyperglycemics diabetes medication, they may need to go on insulin prior to surgery
Grajower, M (2011) Diabetes Metab Res Rev 27:413-418
Adjustments of Insulin(s) for Fasting Procedures/Surgeries
BASAL INSULINS
Long acting – Lantus, Levemir, NPH
• PM- basal insulin dose-usual dose EXCEPT if hypoglycemia has been an ongoing issue. If this is the case, the dose can be decreased by 25%
• AM- basal insulin dose-give 1 /2 dose if in optimal control pre-admission, to 2/3 if not in optimal control
KGH Diabetes Management Peri-op/procedure Order Set
Premixed insulin-30/70, 25/75, 50/50
PM- Administer usual dose evening before procedure
AM –Give 1/3 of the pre-mixed insulin dose as NPH ( to represent 50% of basal portion of AM dose) the morning of procedure
KGH Diabetes Management Peri-op/Procedure Order Set (Adult)
KGH and HDH policy is to:
hold all oral diabetes medications am of surgery
hold am prandial insulin.
basal insulin adjustments as specified by anaesthetist
Checking Blood Glucose Morning of Surgery/Procedure.
Hyperglycemia-
Patients using a supplemental insulin scale with rapid insulin can apply it to correct a bloodglucose above 11 mmol/L
Dobri, G & Lansang, MC . Cleveland Clinic Journal of Medicine ( 2013) 80: 702-704
Hypoglycemia-
If blood glucose is < 4 mmol/L , give 125 ml (1/2 cup) of apple juice or non-diet pop ( no milk, honey or fruit juice containing pulp) and recheck BG in 15 minutes.
If BG still <4 mmol/L repeat treatment.
CHEO Physician Orders for Management of Patients with DM treated with Insulin Injections Short Procedures (<2 hours)
Pre surgery –Pumps /Sensors
Patient must bring all insulin pump supplies to the hospital
If procedure < 2 hours – continue usual basal rate settings overnight and day of surgery.
If procedure > 2 hours – will likely transition to IV insulin – pump should be discontinued 30 minutes after IV insulin is started.
KGH Diabetes Management Peri-op/procedure Order Set
Post surgery- Pumps/sensors
At KGH there is a “Patient Self-Management of Insulin Pump Consent Form” detailing the requirements that need to be met in order for a patient to continue to wear their pump in hospital
KGH Policy 14-102 Appendix A
DISCONNECT PUMP FOR:
Pacemaker/Implantable Defibrillator
Cardiac Catheterization
Nuclear Stress Test
Bone Density Scan
Fluoroscopy - Therapeutic Radiation ( cancer)
CT/MRI Scan
Electric-cautery surgery
General Anesthesia ( depends on equipment being used during surgery)
Mammogram
Body/Dental x-rays
Insulin Pump and CGM System Owner’s Booklet
No need to disconnect for :
• EKG
• Ultrasound
• Laser Surgery ( some lasers can cause pump to alarm)
• Colonoscopy
Insulin Pump and CGM System Owner’s Booklet
Diabetes issues related to medical procedures -Colonoscopy Bowel Prep
Guidelines
Two main considerations are getting enough fluids and carbs:
Fluids-
The goal is to drink at least one tall glass of fluid every hour the day before the procedure. Non-carb fluidsto choose from are water, clear broth, sugar-free ginger ale, sugar-free popsicles, sugar-free Jell-O, clear teas. There is no restrictions on the clear no carb fluids.
Patient Information Brochure HDH for Colonoscopy( 2015)
Carbohydrates-
In addition to fluids a patient must meet their needs for carbohydrate every hour. See the list below for the drink ideas and portion sizes for your hourly need during waking hours.
Patient Information Brochure HDH for Colonoscopy( 2015)
List of fluids containing carbs: ( approximately 10 grams)
1/3 cup of apple juice
½ cup of regular ginger ale/ sprite/7-up or
other caffeine- free clear pop)
¼ cup regular Jell-O ( yellow only)
¾ regular popsicle NOT red, purple, green
or chocolate
Two hard candies Patient Information Brochure HDH for Colonoscopy( 2015)
Diabetes issues related to medical procedures
METFORMIN should be temporarily discontinued 48 hours before undergoing radiologic studies involving intravascular administration of iodinated contrast materials, because use of these may result in acute alterations of renal function.
Metformin should be restarted 48 hours post procedure if the eGFR and creatinine are confirmed to be normal. Metformin Monograph
CPG 2015 SADMANS GUIDELINES S = Sulphonylureas A = ACE inhibitors D = Diuretics, direct renin inhibitors M = Metformin A = Angiotensin receptor blockers N = Non-steroidal anti-inflammatory S = SGLT2 inhibitors
Instructions for Healthcare Professionals:
If patients become ill and are unable to maintain
adequate fluid intake, or have an acute decline in renal function (e.g. due to gastrointestinal upset or dehydration), they should be instructed to hold medications which will:
• Angiotensin-converting enzyme inhibitor• Angiotensin receptor blockers• Direct renin inhibitors• Non-steroidal anti-inflammatory drugs• Diuretics• SGLT2 inhibitors
B) Have reduced clearance and increase risk for adverse effects:• Metformin• Sulfonylureas (gliclazide, glimepiride, glyburide)
Please complete the following card and give it to your patient. Patients should be instructed that increased frequency of self blood glucose monitoring will be required and adjustments to their doses of insulin or oral antihyperglycemic agents may be necessary.
Instructions for Patients
When you are ill, particularly if you become dehydrated (e.g. vomiting or diarrhea), some medicines could cause your kidney function to worsen or result in side effects.
If you become sick and are unable to drink enough fluid to keep hydrated, you should STOP the following medications:
• Blood pressure pills• Water pills• Metformin• Diabetes pills• Pain medications• Non-steroidal anti-inflammatory drugs (see below)
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Please be careful not to take non-steroidal anti-inflammatory drugs (which are commonly found in pain medications (e.g. Advil) and cold remedies).
Please check with your pharmacist before using over-the-counter medications and discuss all changes in medication with your healthcare professional.
Please increase the number of times you check your blood glucose levels. If they run too high or too low, contact your healthcare professional.
If you have any problems, you can call:
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S sulfonylureasA ACE-inhibitorsD diuretics, direct renin inhibitors
M metforminA angiotensin receptor blockersN non-steroidal anti-inflammatoryS SGLT2 inhibitors
THANK-YOU FOR YOUR ATTENDANCE AND ATTENTION!