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Perioperative Diabetes MX

This document discusses the perioperative management of diabetes. It outlines the importance of glycemic control during surgery to improve outcomes. Maintaining glucose levels between 8-11 mmol/L can avoid hypoglycemia and acute complications like ketoacidosis or hyperosmolarity. The document recommends using IV insulin infusion for optimal control during longer or more complex procedures. Postoperatively, resuming usual diabetes medications or using IV insulin to closely monitor glucose levels is advised. The document also presents three clinical cases and asks attendees to develop perioperative management plans for each.

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Travis Satnarine
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150 views18 pages

Perioperative Diabetes MX

This document discusses the perioperative management of diabetes. It outlines the importance of glycemic control during surgery to improve outcomes. Maintaining glucose levels between 8-11 mmol/L can avoid hypoglycemia and acute complications like ketoacidosis or hyperosmolarity. The document recommends using IV insulin infusion for optimal control during longer or more complex procedures. Postoperatively, resuming usual diabetes medications or using IV insulin to closely monitor glucose levels is advised. The document also presents three clinical cases and asks attendees to develop perioperative management plans for each.

Uploaded by

Travis Satnarine
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PPT, PDF, TXT or read online on Scribd
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Perioperative Diabetes

Management
Dr. Ken Locke
March 2007

Objectives
At the end of the seminar, you will be able to:
Describe the problems created by inadequate
perioperative glycemic control
Develop a series of goals in the perioperative
management of diabetes, and prioritize them
Explain strategies for managing diabetes, and
apply them to clinical cases

Outline
Clinical cases
Background on perioperative
hyperglycemia
Principles of perioperative diabetes
management
Recommendations
Cases revisited

Clinical Cases
A 25 year old type 1 diabetic woman is
scheduled for hysteroscopy for infertility
What are the important considerations
in her periop management?
What strategies could be used?

Clinical cases cont.


A 72 year old man with type 2 diabetes on
150 units of insulin/day is scheduled for
cataract extraction
What are the important considerations
in his periop management?
What strategies could be used?

Clinical cases cont.


A 58 year old type 2 diabetic woman on
glyburide and metformin is scheduled for AAA
resection
What are the important considerations in her
periop management?
What strategies could be used?

Why is perioperative glycemic


control important?
Improvement in wound healing
parameters (tissue level data)
Improvement in infection parameters
(tissue level and case series)
Improved mortality seen in critical illness,
post CV surgery, and post AMI with
STRICT glycemic control (RCT level data)

Why is perioperative glycemic


control difficult?
Altered glucose inputs
NPO, changes in motility, enteral feeds, TPN

Altered hypoglycemic therapy


Cannot use OHAs
SC insulin may have different absorption profile

Altered glucose homeostasis


Increased counter-regulation in perioperative
environment
Decreased ambulation
Increased tissue consumption after larger surgeries

Principles of Perioperative DM
Management
1st Goal: Avoid intra-operative
hypoglycemia
2nd Goal: Avoid acute complications of
hyperglycemia
3rd Goal: Maintain optimum glycemic
control

Avoid Intraoperative Hypoglycemia


Hypoglycemia is potentially damaging at any
time
Intraoperative hypoglycemia is impossible to
detect clinically
Sympathetic responses are ablated by anaesthesia

Hypoglycemia is more likely intraoperatively


Increased glucose consumption in response to
surgery

Avoid Intraoperative Hypoglycemia


Solution: Support patients with IV D5W who
take any pharmacologic DM therapy
Remember, yesterdays evening doses are peaking
during this mornings OR!

Minimum is 5g of glucose/hour = 100 cc/hour


Also prevents catabolism

Avoid Acute Complications of DM


Type 1 patients are prone to ketoacidosis
But Type 2 patients can develop it with great
stress

Type 2 patients are at risk of


hyperosmolarity
Risk of both of these increases with
duration and complexity of surgery
Direct effects of counter-regulation and fluid
balance

Avoid Acute Complications of DM


Solution:
Ensure adequate insulin is present during
surgery and afterward
Remember that insulin resistance in Type 2
patients may require dose increases
Monitor glucose before, during and after OR
Ensure appropriate fluids are being given to
assist in glucose clearance

Maintain Optimum Glucose Levels


Range of 8-11 typically used
Avoids hypoglycemia but not beyond range of
control

Choose the strategy that fits:


type of surgery (metabolic stress)
duration of surgery
availability of resources

Options
Rely exclusively on residual insulin from
previous days therapy (oral or SC insulin)
Best for short procedures where risk of acute
hyperglycemia is very low

SC long acting insulin (adjusted dose)


May not be adequate for longer procedures

IV insulin infusion with frequent monitoring


of glucose level
Requires time/personnel to monitor and adjust

Best Practices
All patients hold their usual doses on day of
surgery while NPO
No agreement on anything beyond this!
IV insulin preferred to achieve optimum glucose
control
Use for Type 1&2 DM, longer procedures, especially
with significant insulin resistance

SC insulin when IV insulin not necessary


Can be more liberal with Type 2 than Type 1

Yesterdays insulin never for Type 1

Postoperative Management
When patients resume eating, can usually
resume usual therapy
Alterations (NPO, reduced diet, enteral
feeds etc.) require altered management
Oral agents should wait until reliable diet
IV insulin easiest to titrate/achieve control
Remember to anticipate rather than react to
abnormal glucose

Back to the Cases


Develop a plan for each case:
A 25 year old type 1 diabetic woman is scheduled for
hysteroscopy for infertility
A 72 year old man with type 2 diabetes on 150 units of
insulin/day is scheduled for cataract extraction
A 58 year old type 2 diabetic woman on glyburide and
metformin is scheduled for AAA resection

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