09. Perioperative Management of Diabetes Mellitus content

General Considerations

  • Hyperglycemia and hypoglycemia are associated with increased morbidity and mortality in the hospital
  • Factors Impacting Blood Glucose:
    • Surgical stress is associated with release of insulin counter-regulatory hormones and increased insulin requirements, which decreases as recovery ensues
    • Changes in caloric intake, fluctuations in renal or hepatic function, and medication interactions all impact blood glucose management
  • When to treat:
    • Persistent hyperglycemia with BG > 180 mg/dl should be treated; however, studies to define optimal glycemic targets have yielded inconsistent results. (Grade 2C recommendation)
  • How to treat:
    • Med-Surgery/TCU: Ideal insulin regimens consist of 1) basal insulin, 2) nutritional insulin (if patient is eating), and 3) correctional insulin
    • ICU: Use IV insulin infusion in critically ill patients with poor glucose control
  • Avoid: Prolonged therapy with insulin sliding scale (ISS) as the sole regimen for patients with insulin-dependent diabetes is ineffective and results in labile glucose control

Preoperative management

TYPE OF DIABETES

PRE-OPERATIVE MANAGEMENT

Type 2 DM diet controlled

Insulin sliding scale

 

 

Type 2 DM oral agents

1. Hold oral agents AND noninsulin injectables ONLY on the morning of surgery

2. Start insulin sliding scale

2. Restart all oral medications except metformin once patient is eating

3. Metformin should be held until renal function is proven to be stable

 

 

 

 

 

Type 2 DM insulin

&

Type 1 DM

SHORT PROCEDURE

 

HOME REGIMEN

PREOPERATIVE MANAGEMENT

Once daily long-acting AM insulin

1) Give 2/3 of total AM basal+ bolus insulin as a basal dose

2) Hold the mealtime insulin

3) Use ISS until procedure

Twice daily long-acting insulin

1) Give 1/2 of total AM basal+ bolus insulin as a basal dose

2) Hold the mealtime insulin

3) Use ISS until procedure

Continuous infusion pump

Continue basal infusion rate

Once daily long-acting PM insulin AND risk for hypoglycemia

1) Reduce PM basal insulin by 10- 20% the night prior to surgery

2) Hold the mealtime insulin

3) Use ISS until procedure

LONG PROCEDURE

 

Most patients should be managed with an insulin drip started the morning of the procedure

Pearl: All patients with Type 1 DM require basal insulin at all times, even if NPO. Dose reduce by 10-20% if the patient has a history of hypoglycemia

Post-Operative Management

 

MANAGEMENT

 

ICU

1. Insulin infusion should be used to control hyperglycemia in the majority of critically ill patients with BG>180 mg/dl

2. Maintain BG levels between 140 and 180 mg/dl

NEW START INSULIN

EATING/TUBE FEEDS

1. Calculate 0.3-0.6 units/kg/day

2. Give ~50% of the calculated daily units as basal insulin & ~50% as nutritional insulin

3. Divide nutritional dose into equal TID doses for patients eating meals and Q4-6h doses for patients on tube feeds

NOTE: Patients on tube feeds may benefit from a higher percentage of total daily insulin as a basal dose (~60%)

NPO

1. Calculate 0.3-0.6 units/kg/day

2. Give ~50% of the calculated daily units as basal insulin with ISS

TITRATING INSULIN

 

EATING

1. Titrate insulin for goal premeal BG < 140 mg/dL and random BG < 180 mg/dL. BG should not be consistently below 120 mg/dL in the hospital

2. If 2AM or morning BG elevated, increase the basal dose

3. If a premeal BG is elevated, increase the prior meals nutritional dosing

4. If a patient has high sliding scale requirements, add ~50% to the basal insulin and 50% split across the nutritional insulin

NPO

If a patient has high sliding scale requirements, add ~50% to the basal insulin and 50% split across the Q4-6h insulin dosing

HOME ORAL MEDS

EATING

1. Restart all oral medications once patient is eating

2. Metformin should be HELD until renal function is stable

3. Add medications or adjust doses PRN

4. If poor BG control on 2-3 oral meds, start insulin as above

NPO

1. Start SSI

2. If inadequate BG control, start basal insulin at 0.2 u/kg/d

HOME INSULIN +/- ORAL MEDS

EATING

Restart home regimen and titrate insulin as above

NPO

Restart 50% of home basal dose, hold nutritional insulin, and use SSI

 

Pearls:

  • Titrate to pre-meal BG < 140 mg/dL and random blood glucose < 180 mg/dL
  • Lower starting doses (0.3 u/kg/day) are required in lean, malnourished, elderly patients, or in patients with type 1 diabetes or renal insufficiency.
  • See Endocrine: Inpatient Diabetes Guidelines for further recommendations

Griesdale DEG, de Souza RJ, van Dam RM, Heyland DK, Cook DJ, Malhotra A, et al. Intensive insulin therapy and mortality among critically ill patients: a meta-analysis including NICE-SUGAR study data. Canadian Medical Association Journal 2009 April 14;180(8):821-827.

Moghissi ES, Korytkowsk MT, DiNardo M, et al. American Association of Clinical Endocrinologists and American Diabetes Association consensus statement on inpatient glycemic control. Diabetes Care 2009,32:1119-1131.

Finfer S et al. Intensive versus conventional glucose control in critically ill patients. NEJM 2009;360(13):1283-97

Wesorick D, O'Malley C, Rushakoff R, et al. Management of diabetes and hyperglycemia in the hospital: a practical guide to subcutaneous insulin use in the non-critically ill, adult patient. J Hosp Med 2008;3(suppl 5):s17-s28

Inzucchi S et al. Management of Hyperglycemia in the Hospital Setting. NEJM 2006;355(18):1903-1911