Take a moment…Confer with your neighbourAnd try to solve the following word picturepuzzle slides……….

Example: = Head Over Heels

Take a moment…Confer with your neighbourAnd try to solve the following word picturepuzzle slides……….

Example: = Head Over Heels

Diabetes

for

Residents

Surgery

Learning Objectives

1. To learn the definitions of Diabetes and other categories of glucose intolerance.

2. To understand the differences between Type 1 and Type 2 Diabetes Mellitus.

3. To learn some aspects of the practical management of Diabetes.

Diabetes Mellitus

A chronic disorder of metabolism characterized by an absolute or relative deficiency of insulin and hyperglycemia in postprandial and/or fasting states.

When present for prolonged periods, characteristicmicroangiopathic complications (retina, glomerulus,nerve) develop. Clinically, diabetes ranges from asymptomaticto catastrophic.

Criteria for the Diagnosis of Diabetes

FBS > 7.0 mmol/l on 2 occasions

OGGT- 2 hour PG > 11.1 mmol/l

Random PG > 11.1 mmol/l in the presence of symptoms of hyperglycemia

Pre-Diabetes

Impaired Fasting Glucose- 6.1-6.9

Impaired Glucose Tolerance- 7.8-11.1

40% will develop diabetes

No increased risk for microvascular disease

Increased risk for macrovascular disease

Previous Abnormality of Glucose Tolerance

Previously documented self-limited hyperglycemia

Previous gestational diabetes

Increased risk of developing Type 2 diabetes

Potential Abnormality of Glucose Tolerance

First degree family history of Type 2 diabetes Central Obesity

Culture (Aboriginal, African-American, Mexican-American, South-East Asian, Saudi)

Age > 40 years

Previous GDM or Fetal Macrosomia Previous Abnormality of Glucose Tolerance

Hypertension HypercholesterolemiaSchizophrenia/Psychotropic Rx

Potential Abnormality of Glucose Tolerance

Increased Apo B-100Decreased Apo A-1Small compact LDL/HDLFibrinogenPAI-1IL-6/TNF/CRPDecreased AdiponectinHyperuricemiaNASHPCOSSleep Apnea

Recommendations for Screening

1. Persons with one or more risk factors.

2. Pregnant women between wks.24-28.

3. Individuals with possible complications.

4. Persons with classic symptoms ofhyperglycemia.

Screening

Test of Choice- FPG

Positive Screen- FPG- 6.1-6.9

For high risk pts.,annual screeningafter age 25.

Which of the followingis a true statement?

A. A normal blood glucose is up to 7.0.

B. A patient with polyuria and a glucose of 16.7 should have a GTT for confirmation.

C. Patients with pre-diabetes have insulin resistance.

D. Everyone should have annual screening for Type 2 diabetes.

Which of the followingis a true statement?

A. A normal blood glucose is up to 7.0.

B. A patient with polyuria and a glucose of 16.7 should have a GTT for confirmation.

C. Patients with pre-diabetes have insulin resistance.

D. Everyone should have annual screening for Type 2 diabetes.

C. Patients with Type 2 diabetes can not develop diabetic ketoacidosis .

B. Type 2 diabetes is a disease of progressive insulin deficiency.

A. Type 1 diabetes can present at any age.

Which of the following is a false statement?

D. Hyperuricemia is a marker for insulin resistance.

C. Patients with Type 2 diabetes can not develop diabetic ketoacidosis .

B. Type 2 diabetes is a disease of progressive insulin deficiency.

A. Type 1 diabetes can present at any age.

Which of the following is a false statement?

D. Hyperuricemia is a marker for insulin resistance.

A 36 year old woman with Type 2 diabetesis admitted for an elective lap chole. Her insulin regimen consists of Novomix 30, 48 units each morning before Breakfast and 32 units each evening before supper. She also takes Metformin, 1000 mgs.BID.

How would you manage her diabetes peri-operatively?

1. Full insulin dosage the night before surgery.

2. Take morning dosage of Metformin beforeleaving the house.

3. Give 32 units (2/3 of morning dosage) as Novolin NPH with a 1:1 correction sliding scale of Novolin Toronto for BG > 8mm/l.

4. IV of D-5-W at 75 cc/hour.

5. For evening meal at home, give 20 units (2/3 of evening dosage) as Novolin 30/70 with a 1:1 correction dose for BG > 8mm/l as NovoRapid. Continue the sliding scale for 24 hours.

A 56 year old man with a 45 year history of Type 1 diabetes is admitted for elective resection of a carcinoma of the cecum. It is estimated the operative procedure will take 2-3 hours to complete. His insulin regimen consists of Levimir, 12 units QAM and QHS and an adjustable scale of pre-meal NovoRapid with a 1:10 I:CHO ratio and a 1:2 Sensitivity Index. His average daily dose of NovoRapid is 24 units.

How would you manage his diabetes peri-operatively?

1. An IV insulin infusion. Take 50% of his TDDand divide by 24 to give an hourly rate of infusion. This results in an infusion rate of 1 unit/hour targeted to a glucose of 8-12 mm/l. Use a linear sliding scale of 2 units/hour for 12-16 mm/l and 3 units/hour for > 16 mm/l.

2. IV of D-5-W at 75 cc/hour.

3. Do not be in a hurry to resume s/c insulin in the post-op period. The patient must be hungry and able to eat. 4. Don’t forget to overlap your first s/c dose with the IV insulin infusion.

45 YEAR OLD MAN

Hx: 7 YR. Hx OF TYPE 2 DIABETES MAX. DOSES OF GLYBURIDE AND METFORMIN POLYS, FATIGUE, 12 LB. WT. LOSS

PE: OBESE ( WT.= 90 KGS.) BP 150/95 FUNDI IRMA VIBRATION- LOWER EXTREMITIES

LAB: HgbA1C 0.11 TRIGS. 7.5 HDL-CHOL 0.7

1.WHAT ARE THE INDICATIONS FOR INSULIN THERAPY?

2. HOW WOULD YOU START HIM ON INSULIN?

INDICATIONS FOR INSULIN THERAPY

LEVEL OF GLYCEMIC CONTROL

WEIGHT LOSS

MAXIMUM DOSES OF OHA’S

RETINOPATHY

NEUROPATHY

HYPERTRIGLYCERIDEMIA

HOW TO START HIM ON INSULIN

CONSERVATIVE VS. MDI

CONSERVATIVE APPROACH

0.5 UNITS/KG

45 UNITS/DAY

BID 30/70 INSULIN

2/3 QAM 1/3 QPM

30 QAM 15 QPM

MDI THERAPY

0.5 UNITS/KG45 UNITS/DAY50% BASAL 50% BOLUS

50% BASAL = 22 HUMULIN N/DAY= 11N BID

50% BOLUS

I:CHO= 1:10

SI= 1:2

25 y.o. WOMAN

10 YEAR Hx OF TYPE 1 DM

12H 12N/ 10H/ 16H/ 20N

HgbA1C 0.07 ACUTE GASTRO (VOMITING/ DIARRHEA)

HOW DO WE MANAGE HER?

“SICK DAY” RULES

ORAL INTAKE

REHYDRATE- FLAT COKE/ GINGER ALE

4-8 OZS.Q2HALTERNATE SUGAR-CONTAINING WITH SUGAR-FREE DRINKS

NO DAIRY PRODUCTS

NO SOLID FOOD UNTIL HUNGRY AND NO LONGER VOMITING

“SICK DAY” RULES

INSULIN

AT LEAST 2/3 BASAL INSULIN

HUMALOG Q4-6H- 1 UNIT/ 7 GMS. CHO WITH A “REACTIVE” SLIDING SCALE

< 8 NO EXTRA

8-12 +412-16 +8>16 +12

YOUR PATIENT RECOVERS

CONGRATULATIONS!

TRAVELLING TO AMSTERDAM

DEPARTS 6 PM

ARRIVES 9 AM

??INSULIN ADJUSTMENT

REDUCE HS N BY 50%

TRAVELLING HOME

DEPARTS 2 PM

ARRIVES 7 PM

?? INSULIN ADJUSTMENT

DELAY AM HUM N TO PRE-FLIGHT

i.e. 1:30 PM AMSTERDAM =7:30 AM TORONTO

SHE RETURNS HOME, VERY PLEASED WITH YOUR ADVICE!

NOW SHE WANTS TO TRAVEL TO

?? INSULIN ADJUSTMENT

AUSTRALIA

“ RELATIVE” VS. “ABSOLUTE” TIME

BASAL INSULIN EXACTLY 12 HOURS APART

HUMALOG WITH EACH MEAL,BASED ON CHO COUNTING- 1U/7Gms. + AMBIENT GLUCOSE-1:1.4

C. Any peri-op patient with diabetes may be at risk for developing DKA .

B. When diabetes patients are NPO for surgery, their insulin requirements typically decrease.

A. The IV half-life of insulin is 6 minutes.

All of the following statementsare true, except:

D. The sick Type 2 DM patient may be just as difficult to manage as the sick Type 1 DM patient.

C. Any peri-op patient with diabetes may be at risk for developing DKA .

B. When diabetes patients are NPO for surgery, their insulin requirements typically decrease.

A. The IV half-life of insulin is 6 minutes.

All of the following statementsare true, except:

D. The sick Type 2 DM patient may be just as difficult to manage as the sick Type 1 DM patient.

THE END!