DM : Perioperative glycaemia control

1
DM Perioperative glycaemia control

• Moderators Prof Chandralekha/ Dr Chhavi
• Presenter Ranju Gandhi

www.anaesthesia.co.in anaesthesia.co.in_at_gmail.c
om
2
Aggressive control of intraoperative blood
glucose concentrationA shifting
Paradigm?Anesthesiology 2005103

• Poor intraoperative blood glucose control is
  associated with a worsened hospital outcome after
  cardiac surgery in diabetic patients. (Outarra et
  al)
• Anesthesiology 2005103

3
Immediate periop problems in a diabetic

• Surgical induction of stress response
• Interruption of food intake
• Altered consciousness masks symptoms of
  hypoglycemia necessiate frequent BG estimations
• Circulatory disturbances associated anaesthesia
  Sx

4
Perioperative glycaemia control

• Goal 120-200 mg/dl, normal metabolism
• Metabolic effects of surgery
• ?Stress hormones
  ?Carbohydrate
• ?Cortisol,glucagon,GH
  ?Insulin
• ?Epinephrine
• ?Insulin
• ?Resistance to insulin
• Hyperglycemia-------------------------------
  Hypoglycemia
• Glycemia

5
Perioperative complications with Hyperglycemia

• Dehydration, electrolyte metabolic disturbances
• Predisposes to DKA
• Delayed wound healing
• Bacterial infection postop wound infection
• Median glycemic threshold for neutrophil
  dysfunction 200 mg/dl

6
Perioperative complications with Hyperglycemia
(cont)

• Independent risk factor for increase in short
  long term mortality after cardiovascular surgery
• Worsens clinical outcome in nonlacunar
  (atheroembolic) stroke, traumatic brain injury,
  global focal cerebral ischaemia
• Haemorrhagic extension of ischaemic stroke

7
Benefits of normal blood glucose

• Maintenance of normal white blood cell
  macrophage function
• Positive trophic anabolic effects of insulin
• Improved erythropoiesis
• Decreased hemolysis
• Reduced cholestasis
• Less axonal dysfunction

8
Hypoglycemia

• BG 45-50 mg
• Sympathoadrenal (BG ?es rapidly) Weakness,
  sweating, ? HR, palpitations, tremor,
  nervousness, irritability, tingling, hunger
• Neuroglycopenia (BG constantly low)
• Headache, ? temp, visual disturbances,
  mental confusion, amnesia, seizures, coma
• Treatment Unconscious 100 ml 25 D iv or
  Glucagon im/sc

9
Factors considered in selecting a regimen for
glycemic control

• Type of DM
• How aggressively euglycemia sought
• Whether patient takes insulin
• Surgery minor in an ambulatory unit
• Surgery elective or emergency
• Ability of hospital resources

10
Traditional Regimens

• ? No glucose, no insulin
• Limitations
• Not suitable for insulin dependent diabetics
• Pts stores of glucose used to meet increased
  metabolic demands
• Patients taking long acting OHAs predisposed to
  hypoglycemia
• Acceptable for non-insulin dependent diabetics
  minor surgical procedures
• Frequent blood sugar monitoring.
• May require insulin therapy

11
Non tight control regimen

• Aim Prevent hypoglycemia, ketoacidosis,
  hyperosmolar states
• Day before surgery NPO gt midnight
• Day of surgery iv 5D _at_1.5 ml/kg/hr(Preop
  intraop)
• Subcut one half usual daily intermediate acting
  insulin on morning of surgery, increased by 0.5U
  for each unit of regular insulin dose of insulin
  subcut
• Postop Monitor blood glu treat on sliding
  scale

12
Non tight control regimen

• Limitations
• Insulin requirements vary in periop period
• Onset peak effect may not corelate with glu
  cose admn or start of surgery
• Hypoglycemia esp in afternoon
• Lowest therapeutic ratio

13
Tight control regimen I

• Aim 79-120 mg/dl
• Protocol
• Evening before, do preprandial bld glucose
• Begin iv 5D _at_ 50 ml/hr/70 kg
• Piggyback to 5D, infusion of regular insulin (50
  U in 250 ml 0.9 NS)
• Insulin infusion rate (U/hr) plasma glu (mg/dl) /
  150 or /100 if on steroids or severe infection
• Repeat bld glu every 4 hours
• Day of surgery Non dextrose containing
  solutions,
• Monitor blood glu at start every 1-2 hours

14
Tight control regimen II

• Aim Same as TC regimen I
• Protocol Obtain a feedback mechanical pancreas
  set controls for desired plasma glucose.
• Institute 2 iv drips for insulin fluids

15
Albertis regimen

• 1979- Alberti Thomas IV GIK solution 500ml 10
  glucose 10 units soluble insulin 1 gm KCl _at_
  100 ml/hr
• Before surgery - stablize on soluble insulin
  regimen, omit morning dose of insulin
• Commence infusion early on morning monitor glu
  at 2-3 hours
• lt 90mg/dl or gt 180 mg/dl replace bag with 5U or
  15U respectively

16
Albertis regimen-Recent version

• Initial solution 500ml 10 glu 10 mmol KCl
  15 U Insulin, infuse at 100 ml/hr
• Check Blood glu every 2 hours
• Adjust in 5 U steps
• Discontinue if bld glu lt 90 mg/dl

Blood glu (mg/dl) Action
lt120 10 U insulin (2U/h)
120-200 15 U insulin (3U/h)
gt200 20 U insulin (4U/h)
17
Albertis regimen

• Advantages simple, Inherent safety factor,
  balance appropriate
• Criticism hypoglycemia, water load
  hyponatremia, cautious poor renal function
• 20 or 50 D

18
Hirsh regimen

• Aim Normoglycemia
• Infuse glucose 5 g/hr with pot 2-4 mmol/hr
• Start insulin infusion _at_.5-1U/hr
• Measure blood glucose hourly

Blood glu (mg/dl) Action (insulin infusion)
lt 80 Turn off for 30 min, give 25 ml 50 D
80-120 ? by .3 U/h
120-180 No change in infusion rate
180-220 ? by .3 U/hr
gt 220 ? by 0.5 U/hr
19
Regular Insulin Sliding Scale

• RECOMMENDATIONS
• Supplement usual diabetes medications to treat
  uncontrolled high blood sugars
• Short term use (24-48 h) in a patient admitted
  with unknown insulin requirement
• Should not be used as a sole substitute, risk of
  DKA
• Periop changes in regional blood flow
  unpredictable absorption

20
Regular Insulin Sliding Scale
Blood sugar (mg/dl) Low dose scale Mod dose scale High dose scale
lt70 Initiate hypoglycemia protocol Initiate hypoglycemia protocol Initiate hypoglycemia protocol
70-130 0 0 0
131-180 2 4 8
181-240 4 8 12
241-300 6 10 16
301-50 8 12 20
351-400 10 16 24
gt400 12 20 28
21
Split-mixed insulin regimen

• Combining multiple daily injections of
  intermediate or long acting insulin (
  NPH, lente, or ultralente) rapid or
  short acting insulins (Regular,insulin lispro, or
  insulin aspart)
• 1500 Rule (ICF) 1500/total insulin dose
  equals how much 1 unit of regular insulin will
  decrease blood glucose.

22
Intraoperative glucose control

• Subcut insulin not advised potentially erratic
  absorption secondary to altered regional blood
  flow, tissue edema, or fluid shifts during Sx
• Iv bolus of insulin very short half life (8
  min), dangerous iatrogenic hypokalemia,
  hypophosphatemia, hypomagnesimia, hypoglycemia
• Iv insulin infusion preferred
• Adsorption of onto surface of syringes, iv fluid
  bags iv sets - unavoidable problem. Flush line
  discard - saturates insulin binding sites of
  tubing

23
Insulin pumps

• Continuously administer insulin preprations
  (short acting) through a subcutaneous catheter
• Programmed to have variable output throughout
  day, night can administer bolus
• Options Turn off use a continuous insulin
  infusion or continue pump at a basal rate
  supplemented with dextrose K with rate
  adjustment based on serial BG measurement

24
Diabetes Glucocorticoid therapy- Steroid
diabetes

• Minimal elevation of fasting bld glucose
• Exaggeration of postprandial hyperglycemia
• Insensitivity to exogenous insulin
• Preexisting diabetics-profound hyperglycemia
• Variable rate insulin infusion appropriate mode
  of therapy

25
Anaesthesia technique for diabetic patients

• Depends on existing end organ pathology
• Regional anaesthesia
• Pt with AN Profound hypotension with coexisting
  coronary artery, cerebrovascular or renovascular
  d/s
• Increased risk of infection- epidural abscess
  vascular damage
• Peripheral neuropathy presenting later may be
  confused with anaesthetic complication
• At present no evidence alone or in combination
  with GA confer any benefit in terms of mortality
  major complications

26
Potential benefits of regional anaesthesia in
diabetics

• Avoidance of tracheal intubation (stiff joint
  snndrome, gastroparesis)
• Decreasing venous thromboembolism
• Ophthalmic Sx More rapid recovery, earlier
  mobilization, better pain relief, less NV
  earlier oral intake
• Abolishes catabolic hormonal response to surgery
• Preferable to use specific nerve blocks over CNB
• Can report symptoms of hypoglycemia

27
Effect of anaesthetics

• Etomidate ? glycemic response to Sx
• Midazolam At high doses, ?es ACTH/cortisol
  secretion, stimulates GH secretion, net effect ?
  glycemic response to Sx
• Clonidine Improved glycemic control (?ed
  sympathoadrenal activity), ? insulin secretion
• Volatile agents(halothane, isoflurane) T
  glucose stimulated insulin secretion in a dose
  dependent manner

28
General anaesthesia in a diabetic

• Antiaspiration prophylaxis
• Stiff joint syndrome AN Awake FOI
• AN Aim is haemodynamic stability
• IBP Monitor BP lability
• Adequate analgesia
• AN Aggressive intraop measures to maintain
• normothermia

29
Periop management Type II Diabetics
30
Oral hypoglycemic agents

• Sulfonylureas Long acting discontinued 48-72
  hours before surgery, Short acting held night
  before or morning of surgery
• Thiazolidinediones Rosiglitazone, piaglitazone
  omitted on morning of Sx
• Biguanides Metformin discontinued atleast 24 h
  prior to Sx held for 48 h after major Sx
• Alpha-glucosidase inhibitors (acarbose, miglitol)
  have no effect on fasting blood glucose

31
Patient on diet control or OHA
Type of procedure Glucose monitoring requirement Periop glycemic treatment Postop management
Short, simple procedure only before after surgery Diet None OHA Witheld Resume preop diet or drug regimen
Long, complex procedure Before, after surgery intraop Diet None, BSgt 200, GKI OHA Shift to reg insulin preop Continue GKI Same as above
32
Periop management Type II Diabetics

• Poorly controlled preop (gt200 mg) or even if
  well controlled on OHA undergoing major surgery
  Shift to plain insulin preoperatively
• Well controlled Type II taking insulin Treat as
  type I

33
Type I DM or Type II DM on insulin
Type of procedure Glucose monitoring requirement Periop glycemic treatment Postop management
Short, simple procedure Before, after surgery intraop SC insulin regimen Resume preop regimen after pt resumes eating
Long, complex procedure Continuous every 1-2 hours 5D IV insulin regimen Continue iv insulin glu till preop regimen resumed
34
Emergency surgery

• Fast correction of dehydration, hyperosmolarity,
  ketoacidosis electrolyte imbalance
• Severe hyperglycemia treated by one or more iv
  bolus of 5U insulin ? BG lt 200 mg
• Infection Glycemic control elusive until cause
  treated

35
Tighter glycemic control (lt110 mg)

• Aortocoronary bypass
• Surgery with interruption of cerebral blood flow
• Obstetrics
• Critically ill patients (reduction of mortality
  by 34, blood stream infections by 46, ARF
  requiring dialysis by 41, critical illness
  neuropathy by 44 less likely requirement for
  prolonged mechanical ventilation intensive care)

36
GDM

• State of relative insulin resistance (?Estrogen,
  progesterone, cortisol, HPL, TNF a )
• 10 area of expression ß subunit of insulin
  receptors insulin receptor substrate 1
• Diminished tyrosine kinase activity at cell mem
  level
• Exaggerated, pathological level of normal
  physiological adaptations

37
Maternal implications

• 2-3 fold ? risk of preeclampsia
• Delivery by CS
• UTI subsequent pyelonephritis
• Ketoacidosis hyperglycemic crisis
• 50 risk of type 2 DM within 20 years

38
Fetal implications

• Fetal growth disorder still birth
• Still birth after 36 weeks, ? poor glycemic
  control on insulin pregnancy complicated by
  polyhydramnios preeclampsia
• Mech Chronic fetal hypoxia, ? fetal metabolic
  rate, O2 consumption RBC deoxygenation
• Macrosomia Birth wt gt 4-4.5 kg or gt 90 th
  percentile, 50 pregnancies with GDM Shoulder
  dystocia
• RDS, cardiac septal hypertrophy, persistent fetal
  circulation, polycythemia hyperbilirubinemia
• Neonatal hypoglycemia
• Long term complications obesity type 2 DM
  later life

39
Diagnosis

• Screening test At prenatal visit, repeated at
  24-28 week 50 g oral glucose challenge, Plasma
  glu gt 130 mg cut off ( fasting not required)
• ve- 3 hr OGTT
• GDM- 2 abn values

100 g OGTT NDDG criteria Carpentr-Coustan criteria
Fasting 105 95
1 hr 190 180
2 hr 165 155
3 hr 145 140
40
Diagnostic criteria for GDM

• Fourth international workshop-conference on GDM
  recommended Carpenter-Coustan criteria
• Classified into A1 A 2
• A1 Normal FBS adequate control with diet
  alone
• A 2 Elevated fasting or 2 hr PP requiring
  insulin

41
GlucoregulationLabor Delivery
BG (mg/dl) Insulin Dose (U/hr) IVF (RL-D5 or NS)-125 ml/hr
lt80 0 RL-D5
80-100 0 RL-D5
100-140 1 RL-D5
140-180 1.5 NS
180-220 2 NS
gt220 gt2.5 NS
42
IDDM for CS Glycemic management

• Usual dose of insulin night before surgery
• Withold insulin on morning of surgery
• Measure FBS if gt 120, delay surgery, start 5D
  _at_2.55mg/kg/min insulin _at_ 1-5u/hr adjust dose
  to maintain plasma glu 70-120 mg, delay surgery
  until euglycemia maintained for 4 hours
• FBSlt120 mg, give no insulin start IVF without
  dextrose
• ? insulin dose to 60 of antepartum dose in
  postop period with hourly plasma glu monitor

43
IDDM for CS Glycemic management

• Measure FBS on morning of surgery
• Start 5D with insulin infuse _at_ 1-2 U/hr
  glucose _at_ 150 mg/kg/hr adjust the dose of
  insulin glu per hourly to maintain 70-120 mg
• Measure BG each hour
• If glu levels gt 120 mg , treat with a bolus of 1
  unit of insulin increase infusion
• If glu lt 70 mg, administer 2-5 g of glucose

44
Conclusion

• Diabetics at greater risk of periop mortality
  morbidity after major surgery
• Improving glycemic control in both short long
  term improves outcome
• In future, islet cell transplant, artificial
  pancreas, recently modified insulin ( Lispro,
  Glargine), constant infusion techniques will have
  a greater role.
• Appropriate metabolic control in periop period is
  imperative is a attainable goal

45
www.anaesthesia.co.in anaesthesia.co.in_at_gmail.c
om