diabetes for surgeons

8/22/2019 Diabetes for Surgeons

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Dr. Maria Wolfs

Assistant Professor

Endocrinology and Metabolism

St. Michaels Hospital

Diabetes for surgeons


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Outline

Background and evidence

Approach to the perioperative patient with DM The patient

The treatment

The surgery

Case discussions


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DM in hospitalized patients

Approximately 1 in 4 patients admitted to the

hospital has a known diagnosis of diabetes 30% of patients with diabetes require >2

hospitalizations in any given year

High prevalence of diabetes

elderly patients

residents of long-term-care facilities up to one third of adults aged 6575 yr

40% of those older than 80 yr

Umpierrez, GE et al. JCEM 2012;97:16-38


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Perioperative hyperglycemia

Case control studies

increased risk for adverse outcomes in patientsundergoing elective noncardiac surgery

BG values > 11.1 mmol/l associated with

prolonged hospital length of stay

increased risk of postoperative complications

wound infections and cardiac arrhythmias



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Perioperative hyperglycemia

postoperative infections

2.7 times higher in patients with glucose > 12.2mmol/liter than in those with glucose levels below 12.2

mmol/liter

3184 noncardiac general surgery patients perioperative glucose value above 8.3 mmol/liter

associated with increased length of stay, hospital

complications, and postoperative mortality



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Reduced risk of infection

Infection

RR 0.41 (0.21- 0.71)

Murad, MH et al. JCEM 2012;97:49


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Glycemic targets in hospital

non-critically ill patients treated with insulin

premeal glucose of < 7.8 mmol/L random BG of


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Glycemic targets in hospital

Provided that their medical conditions, dietary intake and

glycemic control are acceptable, patients with diabetes should

be maintained on their prehospitalization oral

antihyperglycemic agents or insulin regimens [Grade D,

Consensus].

Perioperative glycemic levels should be maintained

between 5.0 and 11.0 mmol/L for most other surgical

situations, with an appropriate protocol and trained staff to

ensure the safe and effective implementation of this therapyand minimize the likelihood of hypoglycemia [Grade D,

Consensus].

CDA 2008 Clinical Practice Guidelines


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Outline



The treatment

The surgery

Case discussions


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Case #1

52F scheduled for TAH tomorrow am

Type 2 DM x 6 years, obesity Medications

Metformin 1000mg bid

Gliclazide MR 60mg am

Humulin N 20u hs

Atorvastatin 10mg hs Perindopril 8mg


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Case #2

29M MVC multiple fractures and head injury

Type 1 DM since age 4 Medications

Humalog 7-5-7

Lantus 12 units hs

On call to OR


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Case #3

75M POD2 bowel obstruction

Type 2 DM x 10 years A1c 7.6% Medications at home


Gliclazide MR 120mg

Sitagliptin 100mg


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Case #4

58F scheduled for total thyroidectomy for

multinodular goitre Type 2 DM for 10 years A1c 7.3%

Metformin 1g bid

Humulin Mix 25 60-0-40-0


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Case #5

78M POD 5 hip fracture ORIF

Type 2 diabetesMetformin 1000mg BID

Glyburide 10mg BID

Continuous NG feeds - swallowing concerns

BS on oral meds 14-18 mmol/L


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Approach to perioperative DM

The Patient

The Treatment The Surgery


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The Patient

Type 1 or Type 2

Type 1 need insulin at all times!!!Glycemic control A1c, SMBG

Diet

NPO, DAT, clear fluids, NG feeds, TPN

Activity level

Medications Steroids

Organ dysfunction/failure Ischemia


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The Treatment

Oral agents

Insulin Both

9 Basal coverage

9 Correction factor


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Oral anti-hyperglycemic drugs

Class Agents Concern Stop if:

Biguanides Metformin Lactic acidosis CHF, renal insufficiency

(eGFR


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DPPIV

Inhibitors

Sitagliptin (Januvia)

Saxagliptin (Onglyza)

Linagliptin (Trajenta )

Renal impairment:

Sita eGFR


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Insulin 101

TDD = total daily dose of insulin

BASAL insulin = 40% of TDD

BOLUS insulin = 60% TDDBASAL 40%

BOLUS 60%


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Insulin 101


BASAL insulin = 40% of TDD BOLUS insulin = 60% TDD


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Insulin 101


BASAL insulin = 40% of TDD BOLUS insulin = 60% TDD

9 Basal coverage

9 Correction factor


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Insulin 101

BOLUS 60%

BASAL 40%


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Insulin pharmacokinetics

Humulin Novolin Sanofi Onset (h) Peak (h) Duration (h)

BOLUS HumalogRegular NovorapidToronto Apidra- 0.25-0.50.5 1-22-3 34-6

BASAL N

-

-

NPH

Levemir

-

-

-

Lantus

2

2

2

6-8

-

-

12-20

16-20

20-24MIXED Humalog

Mix 25

Novomix 30

Humulin

30/70

Novolin

30/70PUMP

9 Basal coverage9 Correction factor


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Insulin pharmacokinetics


BOLUS HumalogRegular NovorapidToronto Apidra- 0.25-0.50.5 1-22-3 34-6

BASAL N

-

-

NPH

Levemir

-

-

-

Lantus

2

2

2

6-8

-

-

12-20

16-20

20-24MIXED Humalog

Mix 25

Novomix

30

Humulin

30/70

Novolin

30/70PUMP


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Ensuring basal coverage

Usual DM regimen Basal coverage for AM of surgery

Oral agents only Hold until eating

Oral agents + bedtime N Usual dose of bedtime N

Oral agents + bedtime Lantus or Levemir Usual dose of bedtime Lantus or LevemirMixed insulin BID 20% of TDD as morning N

MDI with bedtime N Usual dose of bedtime N

MDI with am and bedtime N 70% of am NMDI with Lantus or Levemir Continue usual dose of Lantus or Levemir

Insulin pump Continue basal rate

Day surgery with anticipated eating soon


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Basal insulin


BASAL N-

-

NPHLevemir

-

--

Lantus

22

2

6-8-

-

12-2016-20

20-24

SubcutaneousN/NPH

40% AM 60% HS

25% q6h

33% q8h

Levemir/Lantus 100% HS Intravenous drip


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Basal insulin = 40% TDD

Home regimen TDD Basal (40% TDD)

Oral agents only Assume 30 units/day

Oral agents +

bedtime insulin

Assume 50 units/day

Mixed insulin BID Calculate daily dose

e.g. 40-0-20-0 = ___ units/dayMDI Calculate daily dose

e.g. Humalog 20-20-20-0 +

Humulin N 16-0-0-24 = ___ units/day

Unknown startingdose

Estimate based on weight (kg)Type 1 kg x 0.3 units/kg/day

Type 2 kg x 0.5 units/kg/day

e.g. 60 kg woman Type 1 ___ units/day

e.g. 100 kg man Type 2 ___ units/day


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Oral agents only Assume 30 units/day 12

Oral agents +

bedtime insulin

Assume 50 units/day 20


e.g. 40-0-20-0 = 60 units/day

24

MDI Calculate daily dose

e.g. Humalog 20-20-20-0 +

Humulin N 16-0-0-24 = 100 units/day

40




e.g. 60 kg woman Type 1 18 units/day

e.g. 100 kg man Type 2 50 units/day

7

40


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IV insulin infusion

Check for institutions pre-printed order set

1. Order insulin concentration 50 units of Humulin R in 500cc D5W

1 unit = 10 cc


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IV insulin infusion



1 unit = 10 cc

2. Order IV fluids

Glucose containing (D5W, :)


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IV insulin infusion



1 unit = 10 cc

2. Order IV fluids


3. Calculate basal rate


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Insulin 101 basal insulin

IV insulin drip rate = daily basal/24 hours

Home regimen TDD Basal IV insulin dripOral agents only Assume 30 units/day

Oral agents +

bedtime insulin

Assume 50 units/day 20 0.8 units/hour

Mixed insulin BID Calculate daily dosee.g. 40-0-20-0 = 60 units/day 24 1.0 units/hour


e.g. Humalog 20-20-20-0 +

Humulin N 16-0-0-24 = 100 units/day 40 1.5 units/hour

Unknown starting

dose

Estimate based on weight (kg)



e.g. 60 kg woman Type 1 18 units/day

e.g. 100 kg man Type 2 50 units/day

7.2

20

0. units/hour

0.8 units/hour

Start infusion at 1 unit/hr = 10 cc/hr Basal rate


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Start infusion at 1 unit/hr = 10 cc/hr

Capillary blood glucose check q1h

Basal rate

May not be feasiblein all settings

C Yu Jan 2012


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IV insulin infusion



1 unit = 10 cc

2. Order IV fluids


3. Calculate basal rate4. Calculate correction factor


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IV insulin infusion



1 unit = 10 cc

2. Order IV fluids


3. Calculate basal rate4. Calculate correction factor

9 Basal coverage9 Correction factor


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Correction factor

1 unit of insulin will lower BG by___mmol/L

= 100/TDD e.g. 70M home insulin regimen Humulin 30/70

30-0-20-0

TDD = ___ units


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Correction factor



30-0-20-0

TDD = 50 units

CF = 100/TDD = 100/50 =___


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Correction factor



30-0-20-0

TDD = 50 units

CF = 100/TDD = 100/50 = 2

1 unit of insulin will lower BG by 2 mmol/L


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Correction factor


= 100/TDD e.g. 60 F home insulin regimen Humulin 30/70

Humalog 6-5-8-0 + Glargine 14 hs

TDD = ___ units

CF = 100/TDD = 100/___ =___



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Correction factor


= 100/TDD e.g. 60 F home insulin regimen Humulin 30/70

Humalog 6-5-8-0 + Glargine 14 hs

TDD = 33 units

CF = 100/TDD = 100/33 = 3

1 unit of insulin will lower BG by 3 mmol/L


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Correction factor (100/TDD)

Target a BG of 6 mmol/L

Start at 6+CFe.g. if TDD = 50 then CF = ___


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Start at 6+CFe.g. if TDD = 50 then CF = 2 then 6+2= ___


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Start at 6+CFe.g. if TDD = 50 then CF = 2 then 6+2=8

Blood glucose (mmol/L) Rapid insulin correction (units)

4.0-8.0 None

8.1-10.0 1

10.1-12.0 2

12.1-14.0 3

14.1-16.0 4

16.1-18.0 5

18.1-20.0 6> 20.1 7 and call MD


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Start at 6+CFe.g. if TDD = 33 then CF = ___ then 6+__=__


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4.0-9.0 None

9.1-12.0 1

12.1-15.0 2

15.1-18.0 3

18.1-21.0 4

> 21.0 5 and call MD

Start infusion at 1 unit/hr = 10 cc/hr Basal rate


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/ /

Capillary blood glucose check q1h

If BG: Give additional bolus of:16.0 5 unit = 50 cc, call MD

If additional bolus required for 2 consecutive hours, increase infusionrate by 0.5 u/hr = 5 cc/hr

If no additional bolus required for 2 consecutive hours, decrease

capillary blood glucose check to q4h

asa ate

Correction factor

May need to adjust

May not be feasiblein all settings

C Yu Jan 2012


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The Surgery

Procedure

Timing Plan to eat


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The Surgery

Procedure

Timing

Plan to eat

Procedure DM regimen

Major cardiovascular IV insulin drip

Likely post-op ICU IV insulin drip

Day surgery Ensure basal coverage until eating

OR


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The Surgery

Procedure

Timing

Plan to eat

Timing DM regimen

Morning case

Afternoon Ensure adequate basal

Unknown Adequate basal or IV insulin drip


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The Surgery

Procedure

Timing Plan to eat

Plan to eat DM regimen

Same day Resume pre-op regimen once eating

POD1 Ensure adequate basal

POD2 or later Adequate basal or IV insulin drip


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Outline



The treatment

The surgery

Case discussions


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Case #1

52F scheduled for TAH tomorrow am

DM2 x 6 years, obesity Medications


Gliclazide MR 60mg am

Humulin N 20u hs

Atorvastatin 10mg hs Perindopril 8mg


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The Patient

Type 1 or Type 2


Diet


Activity level


Organ dysfunction/failure

Ischemia

Type 2

A1c 7.8%


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The Treatment

Oral agents

Insulin Both Metformin

Gliclazide

Humulin N


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Biguinides Metformin Lactic acidosis CHF, renal insufficiency (eGFR


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The Surgery

Procedure

Timing Plan to eat


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Write orders

Basal coverage

Correction factor


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Oral agents + bedtime Lantus or Levemir Usual dose of bedtime Lantus or Levemir

Mixed insulin BID 20% of TDD as morning N


MDI with am and bedtime N 70% of am N

MDI with Lantus or Levemir Continue usual dose



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4.0-8.0 None

8.1-10.0 1

10.1-12.0 2

12.1-14.0 3

14.1-16.0 4

16.1-18.0 5

18.1-20.0 6> 20.1 7 and call MD


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Case #2

29M MVC multiple fractures and head injury

Type 1 DM since age 4 Medications

Humalog 7-5-7

Lantus 12 units hs

On call to OR


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The Patient

Type 1 or Type 2


Diet


Activity level


Organ dysfunction/failure

Ischemia

Type 1

A1c 8.5%

Sedentary post #


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The Treatment

Oral agents

Insulin Both

Humalog 7-5-7-0Lantus 12 hs


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The Surgery

Procedure

Timing Plan to eat


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Write orders

Basal coverage

Correction factor


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MDI with Lantus or Levemir Continue usual dose of Lantus or Levemir


Continue Lantus 12 units hs

l i li %


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Either calculate basal from TDD or use Lantus dose= 12 units/day

Insulin drip rate = basal rate/24 hours

12 units/24 hours = 0.5 units/hour



e.g. Humalog 7-5-7-0 +Lantus 0-0-0-12 = 31 units/day

31 x 0.40 = 12

C i f ( 00/TDD)


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4.0-9.0 None

9.1-12.0 1

12.1-15.0 2

15.1-18.0 3

18.1-21.0 4


C #3


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Case #3

75M POD2 bowel resection

Type 2 DM x 10 years Medications at home


Gliclazide MR 120mg

Sitagliptin 100mg

C #3


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Case #3

75M POD2 bowel obstruction

Type 2 DM x 10 years A1c 7.6% Medications at home


Gliclazide MR 120mg Sitagliptin 100mg

Poor appetite post-op only minimal clear fluids

Blood sugars 13-18 mmol/L

Baseline eGFR >60ml/min Cr 95

Postop Cr 150

C #3


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Case #3

Restart metformin + sitagliptin

Restart metformin + gliclazide + sitagliptin Start sliding scale

Start IV insulin drip

Start basal insulin

Start basal insulin + correction factor

O l i h l i d


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Biguinides Metformin Lactic acidosis CHF, renal insufficiency (eGFR


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DPPIV

Inhibitors

Sitagliptin (Januvia)

Saxagliptin (Onglyza)Linagliptin (Trajenta )

Renal impairment:

Sita eGFR


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Oral agents only Assume 30 units/day 12

Oral agents +

bedtime insulin

Assume 50 units/day


e.g. 40-0-20-0 = ___ units/dayMDI Calculate daily dose

e.g. Humalog 20-20-20-0 +

Humulin N 16-0-0-24 = ___ units/day




e.g. 60 kg woman Type 1 ___ units/day

e.g. 100 kg man Type 2 ___ units/day

W it d


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Write orders

Basal coverage

Correction factor

B l i li 12 it /d


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Basal insulin 12 units/day


BASAL N

--

NPH

Levemir-

-

-Lantus

2

22

6-8

--

12-20

16-2020-24

Subcutaneous

N/NPH 40% AM 60% HS 5 units AM 7 units HS

25% q6h 3 units q6h

33% q8h 4 units q8h

Levemir/Lantus

100% HS 12 units hs Intravenous drip 0.5 units/hour

C #3


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Case #3

Humulin N 5 units AM 7 units HS

Humalog correction factor 100/TDD100/30 = 3


4.0-9.0 None

9.1-12.0 1

12.1-15.0 2

15.1-18.0 3

18.1-21.0 4


C #3


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Case #3

Required 5 units of Humalog correction

Can increase basal insulin by 4 units

Humulin N 7 units AM 9 units HS

Breakfast Lunch Dinner Bedtime

Blood sugar 12.4 10.1 13.6 8.9Humulin N 5 - - 7

Humalog

Correction

+2 +1 +2 0

C #3


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Case #3

Once eating:

If Cr back at baseline Restart oral medications

If Cr remains high

Add Bolus insulin

C #4


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Case #4

58F scheduled for total thyroidectomy for

multinodular goitre

Type 2 DM for 10 years A1c 7.3%

Metformin 1g bid

Humulin Mix 25 60-0-40-0

W it o d


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Write orders

Basal coverage

Correction factor



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e.g. Humalog Mix 25 60-0-40-0

TDD = ___ units/day20% TDD = ___ units N in am



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e.g. Humalog Mix 25 60-0-40-0

TDD = 100 units/day20% TDD = 20 units N in am



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TDD = 100 then CF = 1


4.0-8.0 None

8.1-10.0 2

10.1-12.0 412.1-14.0 6

14.1-16.0 8

16.1-18.0 10

18.1-20.0 12


Case #5


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Case #5

78M POD 5 hip fracture ORIF

Type 2 diabetesMetformin 1000mg BID

Glyburide 10mg BID

Continuous NG feeds - swallowing concerns

BS on oral meds 14-18 mmol/L

Write orders


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Write orders

Basal coverage

Correction factor

Case #5


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Case #5

Start correction factor

estimate TDD of 30 unitsCF = 3


4.0-9.0 None

9.1-12.0 1

12.1-15.0 2

15.1-18.0 3

18.1-21.0 4


Case #5


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Case #5

Required 11 units of Humalog correction/day

Can start basal insulin Humulin N 3-3-3-3 OR

Increase CF to 1:2

06:00 12:00 18:00 00:00

Blood sugar 15.3 15.7 16.1 13.5

Metformin +

Glyburide

9

9

9

9

9

9

9

9

Humalog

Correction

+3 +3 +3 +2

Outline


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Outline



The treatment

The surgery

Case discussions

diabetes for surgeons

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