Perioperative Care For the General Surgical Patient

Linda Lester, MD- OHSU Rob Kyper, MD Southwest Washington Medical Center Sarah Sherington, PharmD Southwest Washington Medical Center

Pre-operative issues- Dr. Lester Intraoperative glycemic control- Dr. Kyper In-Patient management of diabetes in the hospital- Dr. Sherington

Pre-operative Objectives:

Pre-operative evaluation of the diabetic patient Assessing Pre-operative glycemic control

Does pre-op glycemic control correlate with outcomes Recommendation for glucose management pre-op

How common is unrecognized diabetes

Pre-operative Recommendations for Patients with Diabetes

Goal: Maintain euglycemia while minimizing risks for hypoglycemia and other drug related complications

Decrease length of stay and risk of infections

Patients with diabetes: what pre-operative assessment is important?

Document the following

Type of diabetes L ength of time since diagnosis Current management Current glycemic control

HgBA1c Glucometer dta

Presence of complications

Neuropathy Nephropathy Retinopathy

Autonomic neuropathy increase risk of post op gastroparesis and urinary tract infection

Why is pre-op glycemic control important?

Poor glycemic control

Increases dehydration and electrolyte abnormalities Impairs collagen formation and decreases surgical wound strength Increases risk of complications

Medications for diabetes management associated with risks

Can patients stay on their pre admission therapy?

Answer: It depends on the patient, the type of surgery and which therapy they are on

What about metformin?

Metformin is most commonly prescribed medication for type 2 DM
33% of prescriptions in 2001

Bigaunides associated with an increased risk of lactic acidosis

phenformin resulted in 306 cases of lactic acidosis over a 26 year period

A Comparison of Matched Metformin and Nonmetformin Treated patients on Continuous Outcome Variable

Duncan, A. I. et al. Anesth Analg 2007;104:42-50

Copyright restrictions apply.

Other oral agents?

Oral Agents

TZDs- rosiglitazone or pioglitazone

Potential Complications

Used to improve insulin sensitivity

Sulfunylureas-glipizide, glyburide or glimeperide

Increased risk of fluid retention and hypoglycemia Increased risk of hypoglycemia No known risks

Insulin secretagogues, non glucose dependent Sitagliptin (Januvia) Work to slow food absorption, enhance insulin release in glucose dependent manner

DPP-4 Inhibitors

Clinical example

87 y/o female with type 2 DM, HTN, COPD

Admitted for cholecystectomy

2nd Hospital day routine AM lab plasma glucose level of 45 mg/dL, patient confused, responded to IV glucose Reason for hypoglycemia ?
On going use of glyburide

Recommendations for out patient oral agents

Discontinue all diabetic medications on admission

Insulin must be continued in all type 1 patients

Can re-order short acting sulfonylureas (glipizide, glimeperide) and TZDs in very stable patients

Consider insulin therapy for all unstable patients, including those with renal insufficiency or NPO status

Management of Type 1 Diabetes prior to Minor Surgery Procedures

Patients on continuous insulin infusion (insulin pump)
continue with basal rate no bolus should have hospital guidelines on use of personal insulin pumps

Day of procedure if the patient is NPO:

Patient to take basal insulin as scheduled No bolus insulin- short acting insulin including lispro, aspart and glulisine Measure capillary glucose levels prior to procedure and every 24 hours. Administer short-acting or fasting insulin subcutaneously every 24 hours as indicated

Day of procedure if breakfast is allowed:

Patient to take basal insulin as scheduled Can take bolus insulin with morning meal Measure CBGs before and after procedure.

Preoperative management of patients with type 2 DM

Non insulin treated patient

Insulin treated patient

Check HgBA1c prior to surgery Hold oral agents on day of surgery Check fasting blood glucose

Check HgBA1c and fasting blood glucose Hold oral agents on day of surgery Patients with fasting blood glucose < 180

If less than < 180 no use short acting insulin for correction If greater than 180, consider insulin infusion

Patients with fasting blood glucose > 180 consider insulin infusion

of intermediate insulin in am Give normal dose of glargine

Clinical Example

56 y/o male, no prior history of medical problems Involved in MVA requiring emergency surgery for open femoral fracture POD # 3 routine AM glucose elevated at 230 mg/dL

Is this stress or hospital associated hyperglycemia? What are the implications?

What about undiagnosed diabetes?

Prevalence of DM in hospitalized patients

12-26% 38% (chart review of 1886 medical and surgical pts at community teaching hospital) 1/3 with newly discovered hyperglycemia 20-30 % of patients with diabetes are undiagnosed

Prevalence of inpatient hyperglycemia

References: Clement S, Braithwaite SS, Magee MF, et al. Management of diabetes and hyperglycemia in hospitals. Diabetes Care. 2004;27(2):553-91. Umpierrez GE, Isaacs SD, Bazargan N, You X, Thaler LM, Kitabchi AE. Hyperglycemia: an independent marker of in-hospital mortality in patients with undiagnosed diabetes. J Clin Endocrinol Metab. 2002;87(3):978-82.

Relationship between perioperative glucose and postoperative infection

Stress or new hyperglycemia associated with higher in hospital mortality rates (16%) compared with prior history of diabetes

Screening adults for diabetes prior to surgery

Pilot study for 2 weeks 261 patients evaluated

200 without documented diabetes

Mean CBG lower in non DM

But range up to 212 24/200 with CBG > 126

Using POC HGBA1c and CBG Measurements

4 week pilot on cardiovascular intervention unit 146 pts without DM

34 patients with DM No DM=109 DM=145

Mean fasting CBG

HgBA1c correlates but with lower fasting CBG

Importance of unrecognized diabetes

Hospitalization can identify patients with unrecognized diabetes allow appropriate therapy to begin Hyperglycemia on admission worsens outcomes in patients with CABG

HgBA1c predicts poor outcomes in trauma

Identifying At risk Patients

Hyperglycemia from poorly controlled diabetes or in patients with unrecognized diabetes can increases hospital related morbidity and mortality Elevated HgBA1c indicates need for post hospital therapy change in patients with diabetes increases the likelihood of needing therapy after hospitalization Must have routine monitoring of glucose levels and HgBA1c to identify patients

Recommend CBG monitoring on all surgical patients for first 24-72 hours Add HgBA1c to admission labs for all patients with diabetes add for patients that have two CBGs > 140

Intra-operative Glycemic Control

Robert Kyper MD Columbia Anesthesia Group October 12, 2007

Dr. Evil Says.

History of Glycemic Control

Anesthesiologist goals:

Avoid hypoglycemia & severe hyperglycemia No point of care testing Insulin given IV or SQ to few patients

Textbook Training

Anesthesia and Co-existing Disease, 4th

Edition, Stoelting & Dierdorf (2002) Consensus that IDDM patients undergoing surgery be treated w. insulin NO evidence that close glucose control in relatively brief intraoperative period benefits diabetic patients.

Recently

Martinez, EA, Williams, KA, Pronovost, PJ (2007). Thinking Like the Pancreas, Anesthesia and Analgesia, 104, 4-6. In the last 5 years most hospital based physicians including anesthesiologists have NOT changed their practices in regards to glycemic control

Anesthesia Literature

Numerous studies, Cardiac surgery Numerous studies, ICU pts. (the sick) Injured/ischemic brains Notable lack of data for Ortho./ General

Am. College of Endocrinologists & ASA Guidelines

1. Keep glucose below 180 2. Maintain glucose 80-110 in ICU pts. 3. Avoid PO hypoglycemic drugs unless pt. on regular diet 4. Provide basal insulin for those who are insulin deficient 5. Create and implement a hypoglycemia prevention and management protocol

Day of Surgery: How sweet it is

.

Preoperative Blood Glucose Readings

Data from: Vivek K. Moitra, VK, Jason Greenberg, J, & Sweitzer, BJ (2005). Hyperglycemia on the Day of Surgery. ASA Abstracts

Day of Surgery -Then

Criteria for postponing surgery Lack of data for general surgery pts Decreasing surgical risk Greatest risks for bowel surgery, implants, large incisions, brains, carotid, spines

Barriers

D5 containing fluids Dexamethasone (steroid) PONV ppx Stress dose steroids Insulin availability Glucometer availability Hemodynamic management Duration of surgery

Dexamethasone continued

54 yo Male for Thyroidectomy, Type 2 DM Preop. CBG = 169 10 mg desamethasone intraop. Poor post op control on sliding scale and usual scheduled NPH dosing Peak CBG = 390; 10PM that day No complications recorded at discharge

Metformin

Risk of lactic acidosis

Rare, yet mortality of 50% Does not increase in-hospital mortality after cardiac surgery Duncan, Anesth Anal 2007;
104:42-50

Probably benefits out weigh risks

Complications were lower

Less: prolonged intubation, infection, overall morbidities

Infections

Bacterial exposure in OR

Highest rates after abdominal surgery More common, CABG, C-section, Vascular, Joint prosthesis, spinal fusion Most common pathogens are normal skin flora Manage Antibiotics, temp., glycemic control

One to One pt. / provider care

Insulin Pumps

Basal insulin need Leave in running if possible May need to remove for positioning, or surgical field If removed, insulin infusion for longer surgery

Guidelines - Elective Surgery

CBG <200, proceed

Insulin infusion (>3hr.)

CBG 350, postpone surgery until CBG improved

CBG 200-349 treat, and Anesthesiologist discussion with Surgeon, (proceed or delay)

Checking Intra-operatively

Duration 1 hr check if time allows Duration 2 hr check at least once, preferably Q1hr Pt. with CBG 90 check Q1hr

Craniotomy patients, check at least once Craniotomy patients (diabetic, CBG 120, or steroid given) check Q1hr

Avoiding Increases in Blood Glucose

Avoid boluses of D5 containing IV fluid Pre-op. nurses Hanging 500 ml bags of D5LR

More readily identifying IVF as something other than LR Reducing the dose

Dexamethasone; avoid or reduce dose Consider insulin infusion post operatively, if given Alternatively NPH insulin dose and sliding scale coverage

Insulin Administration in the OR

How aggressive?

Keep glucose < 180 4 Column infusion

IV boluses

Useful for short cases in place of drip Useful to augment infusion in longer cases

Transitions

Considered problematic for many aspects of patient care, including glycemic control Insulin infusions to PACU, possibly to floor Coordination with glycemic control team

Peri-operative Care for the General Surgical Patient: The Pharmacists Role
Sarah L. Sherington PharmD Glycemic control/surgical services Southwest Washington Medical Center

Management of the Surgical Patient Pre operative

Instruction sheet given to all diabetics Hold oral diabetic medications day of surgery Give full dose of glargine (Lantus) the night before surgery Give half usual dose of NPH or regular insulin day of surgery In order to reduce complications such as infection, you may be given insulin during your hospitalization, even if you are not currently using insulin.

Identifying The Diabetic Patient

Surgery schedule identifies known diabetic patients Scheduling form changed

Diabetic yes/no

Blood glucose on all patients admitted for inpatient surgery unless documented fasting blood glucose less than 130mg/dl

Glycemic Control Management

Standardized Insulin Infusion 1unit/ml Pre operative orders changed Correction dose insulin orders using insulin aspart Insulin infusion prepared for surgeries over 3 hours Intra operative management: insulin infusion using the 4 column infusion protocol Post operative management Correction dose insulin orders using insulin aspart Insulin infusion

Glycemic Control Pharmacist

Identifies all surgery patients who are diabetic or have a recorded elevated blood glucose Surgery patients include all patients admitted to the two surgery floors or medical/surgery floor not followed by a PCP and all CABG patients transferred from CCU Resource for physicians and nurses with patients with poor glycemic control

Inpatient Management of Hyperglycemia

Hold oral diabetic medications

Order bmp for all patients on metformin Best therapy for patients with a critical illness, changing status or severe hyperglycemia Basal and prandial/nutritional insulin Increase in daily insulin requirement attributed to illness, stress or treatment

Intravenous insulin therapy

Scheduled insulin

Supplemental insulin

PACU: Percent Glucose Readings by Range January 2007 - June 2007

< 40 mg/dl
100

40 - 69 mg/dl

70-180 mg/dl

>= 200 mg/dl

70-180 mg/dl

79.7
80

74.4 67.4 69.6

77.2 80.3

Percent

60

40

>=200 mg/dl

23.4
20

<40 / <70 mg/dl

15.6 10.1
1.2

15.5 12.2
2.5 1.6

15.0

0.0
0

0.0

0.0

0.0

0.0

0.0

0.0

Jan

07

b Fe

07

r Ma

07

Ap

r0

y Ma

07

Jun

07

PACU: Average Blood Sugar January 2007 - June 2007

195

185

Average (mg/dl)

175

168.3
165

155

154.7 154.2 151.7 148.8 150.0

145

Jan

07

Fe

b0

r Ma

07

Ap

r0

y Ma

07

Jun

07

Average Length of Stay

Ave Length of Stay (ALOS) Comparison - Surgery Patients with and without Insulin
12.00 10.00

8.00 W/Insulin W/O Insulin Linear (W/Insulin) Linear (W/O Insulin)

ALOS

6.00

4.00

2.00

0.00

JUN06 9.70 3.79

JUL06 8.44 3.93

AUG06 8.22 3.79

SEP06 8.31 3.93

OCT- NOV06 06 9.42 4.57 8.59 4.06

DEC06 8.59 3.93 Month

JAN07 8.09 3.61

FEB07 9.59 4.15

MAR07 9.36 3.76

APR07 7.88 4.04

MAY07 8.28 3.80

JUN07 7.77 3.49

W/Insulin W/O Insulin

Questions?