an update about how to take care of blood sugar levels during perioperative period

1. PERIOPERATIVE HYPERGLYCEMIA
MANAGEMENT UPDATES
DR. SYEDA AAL E FATIMA JAFRI

2. OVERVIEW
 Pathophysiology of Perioperative hyperglycemia
 Factors affecting perioperative hyperglycemia

3. Stress hyperglycemia
 12-30% of patients who experience intra and/or post-
operative hyperglycemia do not have a history of diabetes
before surgery, a state often described as ‘stress
hyperglycemia.’
 Stress hyperglycemia typically resolves as the acute illness or
surgical stress abates.
 Measurement of HbA1c helps differentiate patients with
stress hyperglycemia from those with diabetes who were
previously undiagnosed.

4. How Stress Hyperglycemia
occurs ?
The stress of surgery and anesthesia
 Increase BSL
 Relative insulin resistance

5. Why hyperglycemia occurs
with surgery?
The stress of surgery and anesthesia causes release of cortisol,
growth hormone and catecholamines.
Cortisol: increases
 hepatic glycogenolysis
 gluconeogenesis
 protein catabolism.
 all of which cause increased blood glucose levels.

6. Why hyperglycemia occurs
with surgery?
Catecholamines:
 glucagon release; which inhibits insulin release.

7. Why hyperglycemia occurs
with surgery?
Other Stress hormones: cause lipolysis and increase in
free fatty acids (FFAs), which inhibit insulin-mediated glucose
uptake.
 This results in a relative state of insulin resistance, most
pronounced on the first postop day and may persist for 9-21
days.

9. Why hyperglycemia needs to
be treated?
Elevated BSL
 impairs neutrophil function.
 overproduction of reactive oxygen species and inflammatory
mediators.
 Hence, direct cellular damage, vascular and immune
dysfunction.
 Thus impairing the wound healing and prolonging the
recovery time.

10. Factors affecting
perioperative
Hyperglycemia

11. Type of surgery
 Anatomic location, degree of invasiveness, intraoperative
fluids increase duration of stress hyperglycemia.
 Thoracoabdominal surgeries versus peripheral surgeries
 Open procedures versus laparoscopic surgeries

12. Type of Anesthesia
 General anesthesia Vs local or neuraxial anesthesia.
 Volatile anesthetic agents inhibit insulin secretion and
increase hepatic glucose production.

13. Pre-operative HbA1C
 pre-op HbA1c > 7% in TKR: wound complications and
infections
 pre-op HbA1c >7% in CABG: higher 5-year mortality rate
 These studies indicate that poor pre-op glycemic control is
associated with an increased rate of complications and
reduced long-term survival after surgery.

14. Prevalence of hyperglycemia in
surgical patients
 General surgery 20-40%
 cardiac surgery 80%
 Kidney transplant recipients 80%

15. Management
 Pre-operative feeding and fasting.
 Preoperative management.
 Intraoperative management.
 Postoperative management.

16. Pre-operative feeding and
fasting
 A nutritional assessment within 24 hours of admission for all
preop surgical patients.
 A component of the pre-op evaluation.
 Dextrose containing solutions are not indicated in diabetic
patients fasting for periods less than 24-48 hours. (ERAS)?
 Prolonged fasting should be avoided in diabetics.

17. Pre-operative feeding and
fasting
Low carbohydrate diets
 facilitate insulin dosing
 improved BSL control
 avoids the catabolic state associated with starvation
 increase insulin sensitivity
 decrease the risk of postoperative hyperglycemia.

18. Pre-operative feeding and
fasting
The metabolic needs
 can be supported by providing 25-35 calories/kg/day.
 Critically ill require 15-25 calories/kg/day.
 A diet between 1800-2000 calories/day is appropriate for
most patients.

19. ORAL MEDICATION USE THE DAY BEFORE OR ON THE DAY OF SURGERY

20. Surgery Insulin Regimens Based on Oral Intake Status Day
Before

21. DAY OF SURGERY INSULIN
REGIMENS
 Glargine or Detemir: 80% of usual dose if patient takes
morning only or twice daily regimen
 NPH 70/30 Insulin: 50% of routine dose if BSL is
>120mg/dl and hold if BSL<120mg/dl
 Rapid and Short acting insulins: Hold

22. Intra-op BSL Control
 Target BSL: under 180mg/dl.
 Hyperglycemia (>180 mg/dL) is treated with subcutaneous
(SC) rapid-acting insulin analogs or with an IV infusion of
regular insulin.
 ambulatory surgery or procedures of short duration (< 4
hours operating room time) are often appropriate
candidates for SC insulin treatment.
 BSL should be monitored 2 hourly with S/C insulin and 1
hourly with I/V insulin.

23. Intra-op BSL Control
 Correctional insulin is defined as the supplemental insulin
provided for BSL > 180 mg/dL.
 Correctional insulin = BSL - 100 / insulin sensitivity
factor
 Insulin sensitivity factor = 1800 / TDD (Total daily dose of
insulin)
 NOTE: The TDD is equivalent to the patient's daily amount of
basal, prandial. Should TDD not be available or if a patient is using
only OHGs, a sensitivity factor (denominator) of 40 provides a safe
calculation for a correctional insulin dose.

24. Post-op Hyperglycemia
Management
BSL monitoring
 right on shifting the patient to PACU in every patient.
 at least 2 hourly on S/C insulin and 1 hourly on I/V insulin.
BSL targets
 140-180 mg/dL.
For day case procedures,
 patients will be continuing their routine hypoglycemic agents before discharge.
BSL >180 mg/dl, start Insulin Infusion after IV bolus.
Hypoglycemia (BSL < 70 mg/dL) should be corrected immediately depending upon the
clinical condition of the patient, conscious level, ability to swallow and oral status. Oral
glucose or I/V dextrose 25% will be appropriate.

25. Correctional IV Insulin Scale Day of Surgery and
Postoperative Surgical Ward Care

26. SUMMERY

27. Thank you!