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ITALIAN CHAPTER
®
ITALIAN CHAPTERRoma, 7-10 novembre 2019
Pankaj Shah, MDEndocrinology
Mayo ClinicRochester, MN 55905
Perioperative Management
Pankaj Shah, [email protected]
Division of EndocrinologyMayo Clinic, Rochester, MN USA
ITALIAN CHAPTER
®
ITALIAN CHAPTERRoma, 7-10 novembre 2019
Speaker Disclosure
§ I, acting as chairman, speaker, tutor, teacher in the events organizedby Nord Est Congressi state that I have not had financial relationshipwith the any manufacturer(s) of healthcare product(s) or provider(s)of healthcare service(s) in the last two years.
ITALIAN CHAPTER
®
ITALIAN CHAPTERRoma, 7-10 novembre 2019
Objectives
• Should I be screening for diabetes preoperatively in patients who are at risk?
• When would I recommend postponing an elective surgical procedure because of poor diabetes control?
• When should I stop home diabetes medications?• How should I manage patients on insulin pumps in
the perioperative period?
ITALIAN CHAPTER
®
ITALIAN CHAPTERRoma, 7-10 novembre 2019
Objectives
• Should I be screening for diabetes preoperatively in patients who are at risk?
• When would I recommend postponing an elective surgical procedure because of poor diabetes control?
• When should I stop home diabetes medications?• How should I manage patients on insulin pumps in
the perioperative period?
ITALIAN CHAPTER
®
ITALIAN CHAPTERRoma, 7-10 novembre 2019
Undiagnosed DM in Surgical Patients
• Very high incidence of undiagnosed DM• Patients with undiagnosed DM have higher
morbidity and mortality than both non-diabetics and those with known diabetes
Study Patient population % DM or IFGAbdelmalak 2010 39,344 non-cardiac surgery 10% DM, 11% IFGSheehy 2012 Insured, elective surgery,
recent PCP visit24% DM or IFG
Lauruschkat 2005 7310 CABG patients 5.2% DM
ITALIAN CHAPTER
®
ITALIAN CHAPTERRoma, 7-10 novembre 2019
Effect of Intraoperative Glucose on Clinical Events
Gandhi et al Mayo Clin Proc 2005
ITALIAN CHAPTER
®
ITALIAN CHAPTERRoma, 7-10 novembre 2019
Intraoperative Glucose & Event Rates
after Gandhi et al Mayo Clin Proc 2005
0
10
20
30
40
50
60
70
80
<100 100-119 120-139 140-159 160-179 180-199 >200
%
Mean Glucose
ITALIAN CHAPTER
®
ITALIAN CHAPTERRoma, 7-10 novembre 2019
Pre-operative Screening for Diabetes Mellitus
• All patients above 45y if not screened recently• Known IFG or IGT• Patients below 45y if BMI >25 kg/m2 and
• Family h/o DM in first degree relative• High risk ethnicity• Cardiovascular disease, HTN, Dyslipidemia• PCOS, GDM or baby birth weight >4 kg• Physical inactivity• Severe obesity, acanthosis
ITALIAN CHAPTER
®
ITALIAN CHAPTERRoma, 7-10 novembre 2019
Objectives
• Should I be screening for diabetes preoperatively in patients who are at risk?
• When would I recommend postponing an elective surgical procedure because of poor diabetes control?
• When should I stop home diabetes medications?• How should I manage patients on insulin pumps in
the perioperative period?
ITALIAN CHAPTER
®
ITALIAN CHAPTERRoma, 7-10 novembre 2019
Elective surgery in patients with Diabetes: To proceed or not
• Postpone surgery if evidence of metabolic decompensation like Diabetic Ketoacidosis or Hyperglycemic Hyperosmolar State
• Severe hyperglycemia (? > 350 mg/dL) which would increase risk for metabolic decompensation
ITALIAN CHAPTER
®
ITALIAN CHAPTERRoma, 7-10 novembre 2019
Pre-operative Hemoglobin A1c
• No studies have examined benefit of delaying surgery to improve glucose control and outcomes
• Reasonable (but not necessary) to postpone elective surgery if HbA1c >8%, and obtain specialist consultation
ITALIAN CHAPTER
®
ITALIAN CHAPTERRoma, 7-10 novembre 2019
Objectives
• Should I be screening for diabetes preoperatively in patients who are at risk?
• When would I recommend postponing an elective surgical procedure because of poor diabetes control?
• When should I stop home diabetes medications?• How should I manage patients on insulin pumps in
the perioperative period?
ITALIAN CHAPTER
®
ITALIAN CHAPTERRoma, 7-10 novembre 2019
Managing Perioperative Hyperglycemia: Type 1 DM
• Never stop basal insulin• Never stop bolus insulin if patient is eating• Look out for hypoglycemia: Decrease basal insulin
(25-50%) if it appears to be excessive:• Nocturnal or early morning hypoglycemia• Overnight decline in blood sugars• Need for bedtime snack to avoid hypoglycemia• Skewed basal:bolus ratio
ITALIAN CHAPTER
®
ITALIAN CHAPTERRoma, 7-10 novembre 2019
ITALIAN CHAPTER
®
ITALIAN CHAPTERRoma, 7-10 novembre 2019
Diabetes Medications Before Surgery
On the Day before surgery• No change except for possible reduction in long acting insulin at
night if there is concern for hypoglycemiaOn the Day of surgery• Oral medications and non-insulin injectables
• Do not take in the morning• Insulin therapy
• Basal: NPH – half dose; long acting – no change unless concern for hypoglycemia
• Bolus: Hold when NPO, resume with meals
ITALIAN CHAPTER
®
ITALIAN CHAPTERRoma, 7-10 novembre 2019
Simha and Shah, JAMA 2019
ITALIAN CHAPTER
®
ITALIAN CHAPTERRoma, 7-10 novembre 2019
Unaddressed Questions
• Metformin• SGLT-2 inhibitors
ITALIAN CHAPTER
®
ITALIAN CHAPTERRoma, 7-10 novembre 2019
Recent metformin in patients undergoing cardiac surgery
Variable Odds ratio and 95% CIMortality 0.5 (0.1, 2.0)Cardiac morbidity 0.3 (0.1, 1.7)Prolonged intubation 0.3 (0.1, 0.7)Renal morbidity 0.3 (0.1, 1.4)Neurologic morbidity 0.9 (0.3, 2.6)Infection morbidity 0.2 (0.1, 0.7)Overall morbidity 0.4 (0.2, 0.8)
Duncan Anesth Analg 2007;104:42-50No increased risk of adverse events?? Possible beneficial effects
ITALIAN CHAPTER
®
ITALIAN CHAPTERRoma, 7-10 novembre 2019
Glycosuria(urinary loss of glucose)
Natriuretic(urinary loss of sodium)
SGLT-2 inhibitors (‘gliflozins)canagliflozin (Invokana®), dapagliflozin (Farxiga®), empagliflozin
(Jardiance®), ertugliflozin (Steglatro®); Ipragliflozin (Suglat®); Tofogliflozin (Apleway®, Deberza®)
Hyperkalemic(increases serum potassium)
ITALIAN CHAPTER
®
ITALIAN CHAPTERRoma, 7-10 novembre 2019
Ketoacidosis with SGLT-2 Inhibitors
• Over 180 days follow up• Risk 2.2 (1.4–3.6)
• If not on insulin 2.5 (1.1–5.5)
Fralick et al NEJM 2017Peters et al Diab Care 2015
Taylor et al J Clin Endocrinol Metab. 2015
ITALIAN CHAPTER
®
ITALIAN CHAPTERRoma, 7-10 novembre 2019
Fadini et al. Diabetologia. 2017
0
1000
500
150020
14 Q
120
14 Q
220
14 Q
320
14 Q
420
15 Q
120
15 Q
220
15 Q
320
15 Q
420
16 Q
120
16 Q
220
16 Q
3
Type 2 DM
Type 1 DMOther DM
Total
Num
ber o
f rep
orts
SGLT-2 Inhibitor AssociatedDiabetic Ketoacidosis
2500
2000
Unknown Type of DM
ITALIAN CHAPTER
®
ITALIAN CHAPTERRoma, 7-10 novembre 2019
Sloan et al Endocrinol Diabetes Metab Case Rep. 2018
Bloo
d gl
ucos
e (m
g/dL
)
03672
108144180216
Day 1 Day 2 Day 3 Day 4 Day 5
Beta-hydroxybutyrate (mm
ol/L)
0123456
ITALIAN CHAPTER
®
ITALIAN CHAPTERRoma, 7-10 novembre 2019
Kelmenson et al. J Investig Med High Impact Case Rep. 2017
ITALIAN CHAPTER
®
ITALIAN CHAPTERRoma, 7-10 novembre 2019
SGLT-2 inhibitor in Type 1 diabetes?
Dapagliflozin (Farxiga®)• Dandona, et al (Depict 1) Lancet Diabetes Endocrinol. 2017• Mathieu, et al (Depict 1) Diabetes Care. 2018
Sotagliflozin (? Zynquista®): SGLT1 & SGLT2 inhibitor• Garg, et al (inTandem 3) NEJM 2017• Danne, et al (inTandem 2) Diab Care 2018• Buse, et al (inTandem 1) Diab Care 2017
Empagliflozin (Jardiance®)• Shimada et al Diabetes Obes Metab. 2018• Famulla et al (EASE1) Diabetes Technol Ther. 2017
ITALIAN CHAPTER
®
ITALIAN CHAPTERRoma, 7-10 novembre 2019
SGLT-2 Inhibitors and Type 1 Diabetes
Trial no. SotagliflozinEvents/N (/100 pt-yr)
Placebo Events/N (/100 pt-yr)
Hazard ratio Adjusted risk diff^ /100 pt-yr
Number needed to harm /yr
309/310 35/1,049 (3.40)
1/526 (0.19)
17.57 (2.4, 128.2)
3.21 (2.04, 4.38)
31 (22.8, 49.0)
312 21/699 (6.00)
4/703 (1.11)
5.37 (1.84, 15.64)
4.89 (2.17, 7.60)
21 (13.2, 46.1)
^: Exposure-adjusted Mantel-Haenszel risk difference
Wolfsdorf & Ratner Diab Diab Care 2019
ITALIAN CHAPTER
®
ITALIAN CHAPTERRoma, 7-10 novembre 2019
SGLT-2 Inhibitors
SGLT-2 inhibitor associated Diabetic Ketoacidosis• Type 2 diabetes >> Type 1 diabetes• Often another stress: surgery/ vascular event/ infection• Effect of SGLT-2 inhibition lasts for >2-3 days
• Current Protocol: stop on the day of surgeryImplication:• Stop SGLT-2 inhibitor 3-7 days before surgery.• Definitely stop for 3-7 days in Type 1 diabetes!!
ITALIAN CHAPTER
®
ITALIAN CHAPTERRoma, 7-10 novembre 2019
Objectives
• Should I be screening for diabetes preoperatively in patients who are at risk?
• When would I recommend postponing an elective surgical procedure because of poor diabetes control?
• When should I stop home diabetes medications?• How should I manage patients on insulin pumps in
the perioperative period?
ITALIAN CHAPTER
®
ITALIAN CHAPTERRoma, 7-10 novembre 2019CSII (insulin pump) vs Insulin infusion
Corney J Diab Sci Technol 2012;6(5):1003-1012
Continuation of Basal RateConversion to Intravenous InfusionSuspension (intermittent bolus)
0
20
40
60
Perc
ent S
urgi
cal C
ases
BG <70 In Target(70-179)
BG 180-<249 BG ³250
ITALIAN CHAPTER
®
ITALIAN CHAPTERRoma, 7-10 novembre 2019Preparation for surgery in patients on Insulin pump
• Continue usual basal insulin• Subcutaneous Pump or IV Insulin
• Bolus insulin: diet resumed; IV bolus to correct• Appropriate for surgery <2 hours
• not if prolonged surgery, vascular compromise or pump insertion site close to operative field
• Continuous glucose monitoring systems & closed loop system not validated in perioperative phase
ITALIAN CHAPTER
®
ITALIAN CHAPTERRoma, 7-10 novembre 2019
Conclusions
• Screen: all above 45, also if <45 + risk factor(s).• Postpone if elective surgery: DKA/ HHS
• HbA1c >8%• Stop Meds: All non-insulin and bolus insulin;
• NPH insulin: half; basal insulin: usual if appropriate• SGLT-2 inhibitors stop 3-7 days before procedure
• OK to use pumps for procedures less than 2 hours.• If type 1 diabetes – ALWAYS provide basal insulin?
ITALIAN CHAPTER
®
ITALIAN CHAPTERRoma, 7-10 novembre 2019
Pankaj Shah, M.D.Endocrinology, Mayo Clinic,
Rochester MN 55905