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DM : Perioperative glycaemia control

Moderators : Prof Chandralekha/ Dr Chhavi

Presenter : Ranju Gandhi

www.anaesthesia.co.in anaesthesia.co.in@gmail.com

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Aggressive control of intraoperative blood glucose concentrationA shifting Paradigm?Anesthesiology 2005;103

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

Anesthesiology 2005;103

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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

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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 insulinHyperglycemia------------------------------- Hypoglycemia Glycemia

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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

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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

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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

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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

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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

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Traditional RegimensΧ “No glucose, no insulin”

Limitations : 1. Not suitable for insulin dependent diabetics2. Pt’s stores of glucose used to meet increased metabolic

demands3. Patients taking long acting OHAs predisposed to

hypoglycemiaAcceptable for non-insulin dependent diabetics & minor

surgical proceduresFrequent blood sugar monitoring. May require insulin therapy

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“Non tight control” regimen

Aim : Prevent hypoglycemia, ketoacidosis, hyperosmolar states

Day before surgery : NPO > midnightDay of surgery : iv 5%D @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

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“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

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Tight control regimen I Aim : 79-120 mg/dl Protocol Evening before, do preprandial bld glucose Begin iv 5%D @ 50 ml/hr/70 kg Piggyback to 5%D, 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

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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

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Alberti’s regimen 1979- Alberti & Thomas IV GIK solution [500ml

10% glucose + 10 units soluble insulin + 1 gm KCl @ 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

< 90mg/dl or > 180 mg/dl replace bag with 5U or 15U respectively

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Alberti’s 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

< 90 mg/dl

Blood glu (mg/dl)

Action

<120 10 U insulin

(2U/h)

120-200 15 U insulin

(3U/h)

>200 20 U insulin

(4U/h)

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Alberti’s regimen Advantages : simple, Inherent safety factor,

balance appropriate Criticism : hypoglycemia, water load &

hyponatremia, cautious : poor renal function 20% or 50% D

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Hirsh regimen

Aim : Normoglycemia Infuse glucose 5 g/hr

with pot 2-4 mmol/hr Start insulin infusion

@.5-1U/hr Measure blood glucose

hourly

Blood glu (mg/dl)

Action (insulin infusion)

< 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

> 220 ↑ by 0.5 U/hr

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Regular Insulin Sliding Scale RECOMMENDATIONS

1. Supplement usual diabetes medications to treat uncontrolled high blood sugars

2. Short term use (24-48 h) in a patient admitted with unknown insulin requirement

3. Should not be used as a sole substitute, risk of DKA

Periop changes in regional blood flow – unpredictable absorption

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Regular Insulin Sliding ScaleBlood sugar (mg/dl)

Low dose scale

Mod dose scale

High dose scale

<70 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

>400 12 20 28

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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.

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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

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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

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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

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Anaesthesia technique for diabetic patients Depends on existing end organ pathology Regional anaesthesia :1. Pt with AN: Profound hypotension with coexisting

coronary artery, cerebrovascular or renovascular d/s2. Increased risk of infection- epidural abscess &

vascular damage3. Peripheral neuropathy presenting later may be

confused with anaesthetic complication4. At present no evidence alone or in combination

with GA confer any benefit in terms of mortality & major complications

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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

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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) : Θ glucose stimulated insulin secretion in a dose dependent manner

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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

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Periop management : Type II Diabetics

Well Controlled (100-200 mg %)

Diet OHA Insulin

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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

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Patient on diet control or OHAType 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, BS> 200, GKI OHA :Shift to reg insulin preop

Continue GKI +Same as above

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Periop management : Type II Diabetics Poorly controlled preop (>200 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

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Type I DM or Type II DM on insulinType 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

5%D + IV insulin regimen

Continue iv insulin & glu till preop regimen resumed

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Emergency surgery Fast correction of dehydration,

hyperosmolarity, ketoacidosis & electrolyte imbalance

Severe hyperglycemia treated by one or more iv bolus of 5U insulin : ↓ BG < 200 mg%

Infection : Glycemic control elusive until cause treated

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Tighter glycemic control (<110 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)

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GDM State of relative insulin resistance (↑Estrogen,

progesterone, cortisol, HPL, TNF α ) 10 area of expression : β subunit of insulin

receptors & insulin receptor substrate 1 Diminished tyrosine kinase activity at cell

mem level Exaggerated, pathological level of normal

physiological adaptations

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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

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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 > 4-4.5 kg or > 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

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Diagnosis Screening test : At

prenatal visit, repeated at 24-28 week – 50 g oral glucose challenge, Plasma glu > 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

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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

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Glucoregulation:Labor & DeliveryBG (mg/dl) Insulin Dose

(U/hr)IVF (RL-D5 or NS)-125 ml/hr

<80 0 RL-D5

80-100 0 RL-D5

100-140 1 RL-D5

140-180 1.5 NS

180-220 2 NS

>220 >2.5+ NS

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IDDM for CS –Glycemic management Usual dose of insulin night before surgery Withold insulin on morning of surgery Measure FBS; if > 120, delay surgery, start 5%D

@2.55mg/kg/min & insulin @ 1-5u/hr; adjust dose to maintain plasma glu 70-120 mg%, delay surgery until euglycemia maintained for 4 hours

FBS<120 mg%, give no insulin & start IVF without dextrose

↓ insulin dose to 60% of antepartum dose in postop period with hourly plasma glu monitor

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IDDM for CS –Glycemic management Measure FBS on morning of surgery Start 5%D with insulin & infuse @ 1-2 U/hr &

glucose @ 150 mg/kg/hr; adjust the dose of insulin & glu per hourly to maintain 70-120 mg%

Measure BG each hour If glu levels > 120 mg %, treat with a bolus of 1 unit

of insulin & increase infusion If glu < 70 mg%, administer 2-5 g of glucose

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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

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www.anaesthesia.co.in anaesthesia.co.in@gmail.com