Perioperative Diabetes Management in Patients on Insulin
•Download as PPTX, PDF•
6 likes•1,136 views
In these annotated PowerPoints I discuss the control of diabetes in the perioperative period in patients taking insulin. Please download these slides and view them in PowerPoint so you can view the annotations describing each slide.
Recommended
Recommended
More Related Content
What's hot
What's hot (20)
Similar to Perioperative Diabetes Management in Patients on Insulin
Similar to Perioperative Diabetes Management in Patients on Insulin (20)
More from Terry Shaneyfelt
More from Terry Shaneyfelt (20)
Recently uploaded
Recently uploaded (20)
Perioperative Diabetes Management in Patients on Insulin
- 1. Perioperative Diabetes Management: Insulin Terry Shaneyfelt, MD, MPH Assoc. Professor, UAB Department of Medicine The information contained in these slides is for educational purposes only and not meant to guide clinical care. Please refer to package inserts and guidelines for prescribing information.
- 2. There is little evidence on the optimal perioperative management of diabetes
- 3. Goals of glycemic control 1. Avoid hypoglycemia 2. Prevent ketoacidosis and hyperosmolar states 3. Maintain fluid and electrolyte balance 4. Avoid marked hyperglycemia • Optimal perioperative glycemic targets unclear: • ADA: fasting <140 mg/dl for general hospitalized patients (random < 180 mg/dl) • CDA: Perioperative glycemic levels should be maintained between 90-180 mg/dl
- 4. Perioperative glycemia management • No consensus on optimal management strategy to maintain target glucose levels • Surgery should be scheduled as early as possible in the morning to minimize NPO time
- 5. Short Procedures (< 2hrs) • Minor, early morning procedure • Delay usual morning short or rapid acting insulin until postop and right before eating • Long acting insulin or insulin pump: continue usual basal insulin
- 6. Short Procedures (< 2hrs) • Late morning or early afternoon procedure • Omit morning short or rapid acting insulin • AM mixed insulin (Intermediate insulin or long + rapid acting) • 1/2 - 2/3 of usual total morning dose as NPH or long acting • BID mixed insulin • 1/3-1/2 of usual total morning dose as NPH or long acting • Insulin pump: continue basal infusion rate • D5W or D5 1/2NS @ 75-125 cc/hr • Check hourly blood sugar • Correction short acting insulin for hyperglycemia
- 7. Long and complex procedures • IV insulin preferred • Short half life (5-10 min)- more precise titration • Less variable glucose vs SQ route • Begin insulin infusion prior to surgery to achieve glycemic control • Glucose is also needed • GIK infusion- start 100cc/hr & titrate • Separate insulin and glucose IV solutions (5-10 gm/hr)
- 8. Long and complex procedures • Initial insulin infusion rate (U/hr) • Blood glucose level ÷ 100 • Check glucose levels Q 1-2 hrs • Titrate insulin infusion • 120-160 mg/dl: increase by 0.5 U/hr • 160-200 mg/dl: increase by 1 U/hr • >200 mg/dl: increase by 2 U/hr • Never d/c insulin in type 1 diabetes
- 9. Postop treatment • Once the patient is eating well resume preop regimen • Insulin infusion • 1st dose of SQ insulin must be given before stopping IV • Intermediate or long acting: 2-3 hrs prior to stopping IV insulin • Short or rapid acting: 1-2 hrs prior to stopping IV insulin • If not eating well continue IV dextrose (5-10 gm/hr)
- 10. Knowledge Check • You are asked to see a 67 yo M with type 2 DM in the 1 day prior to CABG. He uses 70/30 insulin 40U in the am and 30U in the pm as an outpt. Last A1C 7.5%. Glucose 1 hour ago was 188 mg/dl. What do you recommend? A. Cont usual dose of 70/30 today and give 20 U NPH the morning of the procedure B. Usual home dose of 70/30 insulin with frequent glucose checks C. Begin glucose & insulin infusion today at an initial rate of 2 U/hr D. Begin glucose & insulin infusion early in the morning prior to surgery at an initial rate of 2 U/hr E. Convert to glargine 40U SQ on the morning of surgery
Editor's Notes
- These PowerPoints will review glycemia management during the perioperative period in diabetic patients on insulin.
- There is little evidence to guide the optimal management of diabetes in the perioperative period. Some is extrapolated from studies of the management of hospitalized patients with diabetes. Much of it is opinion.
- There are 4 broad goals of glycemic control in the perioperative period: avoid hypoglycemia, avoid marked hyperglycemia, avoid ketoacidosis, and maintain fluid and electrolyte balance. The optimal perioperative glycemic targets are unclear and based on opinion (Canadian guidelines) or based upon goals for hospitalized patients in general (ADA).
- Opinions vary as how to best maintain blood glucose in the target range. Surgery should be scheduled in early morning to minimize NPO time and to minimize disruption of the management routine.
- For minor early morning procedures in which breakfast is only delayed patients can continue their usual long acting insulin but should delay short or rapid acting insulin until after surgery right before eating.
- For procedures that are later in the morning or early afternoon (in which both breakfast and lunch are missed or delayed) should follow the recommendations on this slide. I personally use the ½ of total am dose as NPH as this is easy to remember. Don’t forget to give some glucose as either D5W or D5 1/2NS to provide some glucose. Check blood sugars hourly and if hyperglycemia develops give correction insulin
- For long complex procedures an insulin infusion is preferred. IV insulin has a short half life and allows for more precise titration. It also is predictably absorbed and thus results in less variable glucose levels vs the SQ route. The insulin infusion should be begun prior to surgery to achieve a steady state glycemic control. Glucose is also needed. It is supplied as a GIK infusion (glucose-insulin-potassium) or as separate insulin and glucose infusions. GIK is somewhat harder to titrate as it comes with premixed concentrations of insulin (usually 15U in 500 cc dextrose).
- To determine the initial insulin infusion rate divide the blood glucose level by 100 yielding the units/hour to be infused. For example, if the blood glucose is 300 mg/dl then start infusing 3 U of insulin per hour. Glucose should be checked every 1 to 2 hours. If the desired blood glucose is not achieved then titrate by the suggested scale above. If hypoglycemia developed reduce insulin infusion rate by 0.5 U/hr. Importantly, never stop insulin in type 1 diabetics to avoid ketosis.
- Once the patient is eating well they can resume their preop regimen. If the patient was on an insulin infusion the first SQ dose must be given prior to discontinuing the IV insulin. Intermediate or long acting insulin is given 2-3 hrs prior to stopping the IV whereas short or rapid acting insulin is given 1-2 hrs prior to stopping the insulin infusion. If the patient is not eating well continue the IV dextrose infusion.
- A is incorrect because the patient is undergoing a complex procedure. This would be reasonable for minor procedure. B is incorrect because insulin requirements will change drastically with CABG and this regimen would be hard to titrate. C is incorrect because the insulin infusion would not need to be started so soon. The patient can continue his home regimen the night prior to surgery then start the IV insulin early on the morning of surgery. D is correct. An insulin infusion will be needed for this complex procedure and should be started early on the morning of surgery. E is incorrect because this patient is undergoing a complex procedure and glargine would be difficult to titrate as it is long acting.