Peri-Operative Diabetic Patient Management Larry Field, MD Critical Care Anesthesiologist Medical...

Peri-Operative Diabetic Patient Management

Larry Field, MDCritical Care Anesthesiologist

Medical University of South CarolinaApril 20, 2010

Objectives• Update our knowledge of different

insulin preparations• Update our knowledge of non-insulin

(oral and injectable) agents• Set reasonable goals for perioperative

glycemic control• Suggest recommendations for

achievement of glycemic goals

• Disclaimers: None

Diabetes Mellitus

• Metabolic diseases characterized by hyperglycemia resulting from defects in insulin secretion, insulin action, or both

• Affects 8% of general population

• 20% of persons aged 65 to 74

• 30-40% of those born this past decade

JAMA 2003;290:1884–90

Curr Opin Anaesthesiol 22:718–724

Insulin Regimens

Humalog/ Novolog

Humalin/ Novolin

Lantus

Levemir (detemir)

Non-insulin Agents

Alpha-glucosidase inhibitors

• Acarbose (Precose), miglitol (Glyset)

• Inhibit oligosaccharide and disaccharide uptake at intestinal (brush border) level

• If NPO, doesn’t do anything

Biguanide• Metformin (Glucophage)

• Inhibition of gluconeogenesis in the kidneys and liver

• Bind to the Mitochondrial membranes, leading to decreased ATP and increased AMP• Limited hypoglycemia potential• Lactic acidosis black box warning• Classically hold for 48hrs

• Eliminated by kidneys

Diabetes Care 2004; 27:1791-1793

Sulfonylureas

• Endogenous insulin release from beta cells• Can cause

hypoglycemia• Hold on morning of

surgery

www.endotext.org

Meglitinides

• Nateglinide (Starlix), repaglinide (Prandin), repaglinide/metformin (PrandiMet)

• Induce endogenous insulin release similar to sulfonureas• Hypoglycemic risk reduced?

• Quick/short action • Taken prior to each meal

Thiozolidinediones (glitazones)

• Troglitazone (Rezulin), rosiglitazone (Avandia), pioglitazone (Actos)

• Transcription factor (PPAR)agonist

Insulin receptor sensitization

• Also improves lipid profiles

• No lactic acidosis

• Limited potential for hypoglycemia

• Hepatotoxicity and fluid retention concerns

• Short plasma half-life; Long duration of action

Combination Pills

Incretin hormones?

• GI hormones released in response enteral carbohydrate load

• Glucose-dependent insulinotropic polypeptide (GIP)• Increased insulin release from beta cells

prior to hyperglycemia

• Glucagon-like peptide 1 (GLP-1)• Neuroendocrine signal

GLP-1• Alpha cells:

• Glucose-dependent glucagon inhibition

• Beta cells:• Primes glucose-dependent insulin

release• Increases beta cell numbers• Increases insulin biosynthesis

• Reduces appetite; slows gastric emptying

Dipeptidyl peptidase IV

• Ubiquitous

• Involved in hormone degredation• GLP-1, VIP, GHRH, neuropeptide Y• GLP-1 is quickly degraded

• Involved in immune cell messaging

Amylin

• Produced by pancreatic beta cells similar to insulin

• Independent/additive effects to insulin

• Glucose-dependent glucagon suppression

• Satiety and delayed gastric emptying

Newest Agents

SQ

PO

SQ

Anesth Analg 2009;108:1803–10

Little anesthetic experience with these agentsBased on physiology and pharmacology

Surgery as a Metabolic Challenge

• Stress hormones – catecholamines, cortisol, growth hormone

• Cytokines – IL-6 and TNF-alpha

• Hyperglycemia proportional to insult• Superficial: 10-20 mg/dl• Major vascular/cardiac: 50-100 mg/dl

Stress-induced hyperglycemia

• Adaptive response• Brain and red blood cell uptake is

increased

• Independent risk factor for morbidity and mortality

Hyperglycemia

• Impaired collagen production

• Impaired neutrophil chemotaxis, phagocytosis, and bacterial killing

• Increased platelet aggregation

• Infectious complications

Clinical Diabetes 2009; 27:82-85

Hypoglycemia

• Sympatho-adrenal activation

• Diaphoresis, tachycardia, hypertension

• Weakness/fatigue AMS Coma

• Common in Type 1 diabetics

• Uncommon in Type 2 diabetics

Intraoperative Glucose Control Data

• Sparse data on outpatient procedures

• Critical care data• Van den Berghe 2001 80-110 goal• NICE-SUGAR 140-180 goal

• Cardiac/surgical data

• Very tight vs good vs poor glucose control

Insulin Benefits

• Decreases endothelial activation

• Improved lipid profiles

• Decreases pro-inflammatory cytokine production

• Benefits thought due to glycemic control

Treatment Goal

• Try to mimic normal metabolism as closely as possible:• Avoiding hypoglycemia• Avoiding excessive hyperglycemia• Avoid ketoacidosis • Avoid electrolyte/fluid disturbances• Avoid large fluctuations

Consensus Recommendations

Typical daily insulin regimen

(DM Type 1: about 50% of daily insulin is basal)

Consensus Statement, SAMBA 2010

POC testing can be off by +/- 20%• 20% of capillary

• 7% of whole blood samples

Mayo Clinic Proc. 2008; 83:394-397



Insulin admin: IV gtt vs IV bolus vs SQ bolus?

• Use 1500 rule for regular insulin

• Use 1800 rule for rapid-acting insulin

Current opinion in anesthesiology 2009; 22:718-724

Insulin Dosing

Current opinion in anesthesiology 2009; 22:718-724

Other Anesthetic Considerationsfor Diabetes Mellitus

• Diabetic comorbidities not covered today

• Periop/stress steroids

Hyperglycemia within a couple of hours

• Starvation increases insulin resistance

Preop carb loading may help

• Beta-blockers can blunt catecholamine-induced hyperglycemia

Other Anesthetic Considerationsfor Diabetes Mellitus

• Etomidate can blunt steroid-induced hyperglycemia of stress

• Volatile anesthetics impair insulin release and increase insulin resistance (dose-dependent)

• Regional anesthesia/local anesthetics can blunt/abolish periop hyperglycemia

• High-dose opioids also blunt

A Final Thought

Continuous glucose monitoring will (soon) be awesome!

Peri-Operative Diabetic Patient Management Larry Field, MD Critical Care Anesthesiologist Medical...

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