Canadian Society of Internal Medicine Annual Meeting 2018 Banff, AB - - PowerPoint PPT Presentation

Canadian Society of Internal Medicine

Annual Meeting 2018

Banff, AB

Diabetes in the post operative period

Dr Lynn A Lambert,

BSC, PhD, MBChB, FRCP (London), DTM&H University of Calgary

CSI M 2018 Ba nff, AB

Disc lo sure s

 Conflict Disclosures

 De finition: A Co nflic t o f Inte re st ma y o c c ur in situa tio ns whe re the pe rso na l

a nd pro fe ssio na l inte re sts o f individua ls ma y ha ve a c tua l, po te ntia l o r a ppa re nt influe nc e o ve r the ir judg me nt a nd a c tio ns.

 I have no conflicts to declare  I have not received any payments from pharmaceutical companies or any honoraria as a speaker

CSIM Annual Meeting 2018

Speaker: Dr Lynn Lambert, October 10 2018

The following presentation represents the views of the speaker at the time of the presentation. This information is meant for educational purposes, and should not replace other sources

• f information or your medical judgment.

Learning Objectives:

Understand the importance of good perioperative care in the diabetic patient undergoing non-cardiac surgery How to manage diabetes in: the neurosurgical patient the patient on corticosteroids the patient who is NPO, on enteral or parenteral nutrition

Why is dia b e te s impo rta nt in the ho spita l se tting

 4th mo st c o mmo n c o mo rb id ity o n ho spita l d isc ha rg e

summa rie s

 Ac ute illne ss c a n c a use a n inc re a se in stre ss ho rmo ne s

a nd se c o nd a ry hype rg lyc e mia

 One US stud y (Umpie rre z e t a l 2002) fo und

hype rg lyc e mia in 38% o f in-pa tie nts; 12% we re no t kno wn to b e d ia b e tic . Ma rke r o f in- pa tie nt mo rta lity

 Blo o d g luc o se is o fte n po o rly c o ntro lle d o n g e ne ra l

me d ic a l a nd surg ic a l se rvic e s

Wha t a re o ur g o a ls fo r dia b e te s c o ntro l in the pe rio pe ra tive se tting ?

Wha t a re o ur g o a ls fo r dia b e te s c o ntro l in the pe rio pe ra tive pe rio d?

Avo id hypo g lyc e mia while pa tie nt is NPO Avo id hypo g lyc e mia while pa tie nt is a ne sthe tise d Avo id hype rg lyc e mia in the po st o pe ra tive pe rio d Optimise d ia b e te s ma na g e me nt fo r pa tie nt’ s re turn ho me c o uld me a n re turn to pre vio us d rug s

• ppo rtunity to intro d uc e insulin a nd a rra ng e te a c hing

Re d uc e in-ho spita l mo rta lity

I s it a mo unta in to c limb ?

Guide line s to he lp us

DIABE T E S CANADA

 2018 In-ho spita l ma na g e me nt o f d ia b e te s  T

a rg e t g lyc e mic le ve ls b e twe e n 5-10 mmo l/ L fo r mino r a nd mo d e ra te surg e ry. Use b a sa l b o lus insulin (no t slid ing sc a le sho rt a c ting )

 Che c k g luc o se 4-6 ho urly; 1-2 ho urly if c ritic a lly ill o r o n iv

insulin (ICU)

 Ma inta in a b o ve 6mmo l/ L

to a vo id a d ve rse e ffe c ts o f hypo g lyc e mia

Guide line s fro m the Assoc iation of

Anae sthe tists of GB & Ir e land

 Pe rio pe ra tive ma na g e me nt o f the surg ic a l pa tie nt with

d ia b e te s, 2015

 A mo re d e ta ile d c he c klist o f wha t to d o with o ra l

re g ime ns a nd insulins.

 De a ls ma inly with pre a nd pe ri-o pe ra tive c a re o f

d ia b e te s

 “Aim fo r intra o pe ra tive g luc o se 6-10mmo l/ L

”

 Do e sn’ t sa y muc h a b o ut po st o pe ra tive ma na g e me nt

Why is g o o d dia b e te s c o ntro l impo rta nt in the pe rio pe ra tive pe rio d?

Risks o f po o r dia b e tic c o ntro l

 I

nc re a se in mo rta lity

 2.4 inc re a se in re spira to ry infe c tio ns  Do ub ling o f surg ic a l site infe c tio ns  3x inc re a se in UT

I

 50% inc re a se in ra te o f MI

a nd Ac ute kidne y injury

 Surg e ry ma y b e a vo ida b ly de la ye d



F risc h, Cha nd ra , Smile y e t a l Dia b e te s Ca re 2010 33: 1783-8

T he po st o pe ra tive pe rio d

 Is influe nc e d b y the pre -o pe ra tive a sse ssme nt o r la c k o f it  A fo c usse d pre -o pe ra tive a sse ssme nt



c a n ma ke the pre -o pe ra tive pe rio d muc h e a sie r to ma na g e



re duc e the risks o f a b o ve me ntio ne d c o mplic a tio ns

T he pre –o pe ra tive a sse ssme nt in the pa tie nt with dia b e te s

 L

• o k fo r e vide nc e o f dia b e te s / pre dia b e te s

 No t a ll pa tie nts a re a wa re o f the ir sta tus  Re c o rd o f pre vio us Blo o d g luc o se , Hb A1c , 

histo ry o f g e sta tio na l dia b e te s, F a mily histo ry



b o dy ha b itus

 Co nside r whe the r the pe ri-o pe ra tive pe rio d c o uld b e dia b e to g e nic

 Hig h do se ste ro id usa g e 

ma jo r pa nc re a tic surg e ry



T PN o r e nte ra l fe e ding like ly

 Me ntio n this in the pre -o p le tte r

GI M c o nsult se rvic e : typic a l in-pa tie nt re fe rra ls

 Patie nt 1  68 ye a r o ld , pre se nte d with se izure s  Ha s Sta g e 4 lung c a nc e r with b ra in me ta sta se s,  L

iste d fo r pa llia tive re se c tio n o f b ra in le sio ns

 Histo ry o f Hype rte nsio n; Dia b e te s o n Me tfo rmin  Ce re b ra l E

d e ma

 Ple a se se e pre -o p a nd fo llo w po st-o p

Yo ur tho ug hts?

Pa tie nt 1

 68 ye a r o ld with b ra in me ta sta se s fro m lung c a nc e r  Hb A1c 2 mo nths a g o 9.0% - po o r c o ntro l  On de xa me tha so ne 4mg q id fo r e de ma  Blo o d g luc o se 14-16 mmo l/ L  Wha t sho uld we do ?  Sto p me tfo rmin pre -o p (a nd do n’ t re sta rt? )  L

a ntus 8 units pre -o p, 14 units po st-o p

 Co nside r ne e d fo r me a ltime sho rt a c ting insulin  Pe rso na lity c ha ng e –who g ive s the inje c tio ns?

Patie nt 2

 84 ye a r o ld , Atria l fib rilla tio n, o n wa rfa rin,  Hype rte nsive ,  Dia b e tic o n Me tfo rmin a nd Sita g liptin  o n urg e nt OR list fo r e va c ua tio n o f sub d ura l he ma to ma .  Co nfuse d  Ple a se d o pre -o p c o nsult a nd pro c e e d with

re c o mme nd a tio ns

T ho ug hts?

Pa tie nt 2 - sub dura l

 Pre -o pe ra tive ly: Me tfo rmin a nd Sita g liptin he ld  Po st o pe ra tive ly: Sug a rs initia lly 8-10 mmo l/ L  BUT

pa tie nt d ro wsy, swa llo w c o mpro mise d

 E

nte ra l fe e d ing sta rte d b y NG ro ute ; d a ytime o nly

 Wha t d id we g ive him?

Pa tie nt 2 -Sub dura l

 Insulin to c o ve r fe e ds  Humulin N (no t L

a ntus) 8 units in the mo rning , titra te d up a s fe e d ra te inc re a se d

 Ne e de d 16 units da ily; sta b ilise d.  T

he n fe e ding c ha ng e d to b o lus a t me a ltime s

 Wha t to do no w?  Wha t to do a s pure e d die t intro duc e d a nd mo b ilisa tio n inc re a se d?  Ba la nc e o f inc re a se d c a lo rie s ve rsus inc re a se d e ne rg y e xpe nditure

Pre a nd po st o p re fe rra ls

Patie nt 3

 On E

NT wa rd :

 74 ye a r o ld , hypo thyro id , 3rd surg e ry fo r he a d a nd ne c k

c a nc e r (pa la ta l re c o nstruc tio n) 2 we e ks po st- o p , no t d o ing we ll

 Dia b e te s, usua lly o n d ie t , Hb A1c 4.9% in 2 mo nths a g o :

pre vio us pa nc re a tic surg e ry; BMI 20

 Wo und b re a king d o wn, no a ppe tite ; g a stro sto my tub e

in situ

 Co nsult: ple a se se e re b lo o d sug a rs 16- 20 mmo l/ L

Pa tie nt 3 – o n the E NT wa rd

 2x 470 c a lo rie c a ns o f milk b a se d liq uid fe e d b y b o lus 3x da ily  Humulin N

 16 u in mo rning , 7 units in e ve ning  Humulin R (o r a spa rt) 6 units a m, 8 units midda y, 6 units e ve ning

 We nt ho me – we c o ntinue d to a dvise a nd g ra dua lly re duc e d insulin a s the

c a ns o f fe e d we re o mitte d a nd die t sub stitute d.

 So ft die t c a n’ t c he w we ll  Me tfo rmin a vo ide d – po o r a ppe tite a nd na use a  Ga ine d we ig ht, do ing we ll

Patie nt 4

 54 ye a rs o ld , o n ne uro surg ic a l wa rd  Rig ht fro nto -pa rie ta l ma ss  d ia b e te s 15 ye a rs, BMI 28, Sub c ut Insulin pump 5 ye a rs  Sa id to ha ve g o o d c o ntro l b ut Hb A1c 8.4%  Just sta rte d De xa me tha so ne , 4mg 6 ho urly  Aske d to se e re : o ptimising b lo o d sug a rs no w a nd

d e a ling with the pe rio pe ra tive pe rio d

Pa tie nt 4

 Pre -b re a kfa st g luc o se is 8-10mmo l/ L

, mid d a y is 18, a fte rno o n is 15, a nd 8pm is 10-12

 Usua l insulin is 0.75 units pe r ho ur. Use s a slid ing sc a le fo r

me a ls.

 “Ca n c o ntro l my o wn insulin”  BUT

sug a rs po o r pre -ste ro id a nd no w o n hig h d o se ste ro id .

 Wha t d id we d o ?

Pa tie nt with the insulin pump a nd the b ra in ma ss

 Re c o g nise d tha t the pa tie nt wa s a n e xpe rt in the wo rking s o f his pump  Re c o g nise d tha t he wa s a little “fro nta l” a nd a nta g o nistic  Inc re a se d the b a c kg ro und ra te to 1.5 units pe r ho ur  Inc re a se d the me a ltime insulin to 10, 12, 8 units  All se t fo r surg e ry  BUT

se nt ho me o n a ta pe ring ste ro id do se to wa it 2-3 we e ks fo r surg e ry.

 Ga ve writte n instruc tio ns a nd a writte n sliding sc a le a nd a c o nta c t numb e r

fo r the dia b e te s nurse

 Ga ve instruc tio ns fo r the pe rio pe ra tive c o ntro l/ to ld the a ne sthe tist

Othe r pa tie nts to c o nside r

 T

he pa tie nt with a pro lo ng e d ile us a nd T PN

 T

he pa tie nt who ha s a pa nc re a tic re se c tio n

 T

he pa tie nt who ha s lo st we ig ht while ill a nd g o e s hypo g lyc e mic whe n his “ho me me ds” a re re sta rte d

Re c o mme nda tio ns

 T

he pe ri- a nd po st- o pe ra tive pe rio d is a g o o d time to re a sse ss the pa tie nt with dia b e te s a nd try to re g a in b e tte r c o ntro l (if a ppro pria te )o r to re la x c o ntro l if life e xpe c ta nc y ha s c ha ng e d.

 A pre -o pe ra tive Hb A1c is re a lly use ful  A tho ug htful pre o p a sse ssme nt o f the dia b e tic pa tie nt is va lua b le  We ne e d to invo lve the pa tie nts a nd the ir fa milie s  Also o ur spe c ia list nurse s, pha rma c ists a nd die tic ia ns  A GIM po st o pe ra tive c o nsulta tio n is re a lly use ful  T

his is a g o o d a re a in whic h to do a Qua lity Assura nc e pro je c t

Re fe re nc e s

 Asso c ia tio n o f a na e sthe tists o f Gre a t Brita in a nd Ire la nd. Pe rio pe ra tive

ma na g e me nt o f the surg ic a l pa tie nt with dia b e te s 2015.

 Anae sthe sia 2015; 70: 1427-1440

 F

risc h A, Cha ndra P, Smile y D, e t a l : Pre va le nc e a nd c linic a l o utc o me o f hype rg lyc e mia in the pe rio pe ra tive pe rio d in no n-c a rdia c surg e ry

 Diab e te s Care 2010; 33: 1783-8

 Dia b e te s Ca nda 2018 Clinic a l Pra c tic e g uide line s

Co mme nts a nd q ue stio ns?