Perioperative Diabetes Management
REVIEW ARTICLEDiabetes ManagementPerioperative diabetes managementTracy L Setji*1, Lisa Gilmore2 & Susan Freeman2ABSTRACTUncontrolled diabetes increases the risk of postoperative complications including surgicalsite infection, acute renal failure, and mortality. Further, the stress of surgery and anesthesiaincrease counter regulatory hormones which contribute to an insulin resistant state and canlead to hyperglycemia, even in patients without known diabetes. Hyperglycemia impairsneutrophil function, and increases inflammatory cytokines and formation of reactive oxygenspecies. These changes lead to cellular damage and dysfunction of the immune and vascularsystems. Recognizing patients at risk for perioperative hyperglycemia during the preoperativeassessment provides an opportunity to intervene on glycemic control. Further, attention toglycemic control on the day of surgery and postoperatively with active management of bloodglucoses with insulin has been shown to improve outcomes. This article reviews perioperativecomplications associated with diabetes and hyperglycemia, and provides guidelines forassessment and management of the patient preoperatively, on the day of surgery andpostoperatively. It also provides a protocol for treating hypoglycemia in the hospital setting.IntroductionDiabetes mellitus affects 30.3 million people inthe United States [1], and an estimated 25%of patients with diabetes will require surgery[2]. Diabetes is a risk factor for postoperativecomplications including surgical site infections,postoperative myocardial ischemia, acuterenal failure, ileus, and increased length ofhospitalization [3-7]. Patients with diabetesare 1.5 times more likely to develop a surgicalsite infection [8]. Each surgical site infection isestimated to cost 7,000 to 38,000 and extendthe length of stay by 10 days [9].In addition to patients with known diabetes,up to 10% of patients presenting for surgerymay have previously undiagnosed diabetes[10,11]. This may lead to higher perioperativeglucoses [10]. Moreover, these patients havea higher risk of mortality in the perioperativeperiod than patients with known diabetes [11].Hyperglycemia noted in surgical or critically illpatients without a known diagnosis of diabetes itis often referred to as stress hyperglycemia [12].Patients with newly diagnosed hyperglycemia inthe hospital have a higher in-hospital mortalityrate (16%) compared with patients with knowndiabetes (3%) and patients with normal glucoses(1.7%; both p 0.01) [13].The pathophysiology behind hyperglycemiaand poor surgical outcomes is complex. Thestress of surgery and anesthesia increase thelevels of counter regulatory hormones, whichsubsequently cause a state of insulin resistanceand raise glucose level. Hyperglycemia hasbeen shown to impair neutrophil function aswell as lead to overproduction of inflammatorymediators and reactive oxygen species leading tocellular damage, and subsequent immune andvascular dysfunction [14,15].Controlling blood glucoses in the perioperativesetting improves surgical outcomes. Cardiacsurgery patients have decreased mortalitywhen glucoses are controlled with continuousintravenous (IV) insulin infusion [16]. Further,a randomized multicenter trial demonstratedimprovement in the composite outcome ofDepartment of Medicine, Division of Endocrinology, Duke University Medical Center, Durham, North Carolina1Center for Advanced Practice, Duke University Medical Center, Durham, North Carolina2*Author for correspondence: tracy.setji@duke.eduDiabetes Manag (2018) 8(3), 067–73ISSN 1758-190767
REVIEW ARTICLESetji, Gilmore, Freemanwound infection, pneumonia, bacteremia,and respiratory failure, and acute renal failure[17]. This review discusses the pathophysiologyand resulting complications of perioperativehyperglycemia, and the management of diabetesin the perioperative period including preoperativeevaluation, day of surgery management, andpostoperative care.chemotaxis, phagocytosis, and bactericidaldestruction [15]. The increase in reactive oxygenspecies from hyperglycemia may result indamage at the cellular level, and immune, andvascular dysfunction [22]. The combinationof these changes likely contributes to the poorwound healing and increased risk of surgical siteinfection in patients with uncontrolled diabetes.Pathophysiology of perioperativehyperglycemiaPreoperative evaluation and treatmentThere are many factors that contribute tohyperglycemia in the perioperative setting. Surgicalstress increases secretion of counter regulatoryhormones including cortisol, catecholamines,growth hormone and glucagon. The impact ofthese excess hormones is widespread. Cortisolstimulates gluconeogenesis and protein catabolism.Catecholamines inhibit insulin secretion andincrease glucagon secretion. Counter regulatoryhormones also increase lipolysis resulting inincreased levels of free fatty acids. Free fatty acidsfurther impair glucose uptake in skeletal muscle.Thus, the cumulative result is an increase in hepaticglucose production, decrease in glucose uptakeand utilization, and inhibition of insulin secretionfrom the pancreas resulting in hyperglycemia andinsulin resistance [14,18].In addition to the surgery and anesthesia,dexamethasone is frequently given during surgeryto help with postoperative nausea and pain andto decrease length of stay [19,20]. However,dexamethasone may also raise blood glucose andthe potential complications related to steroidinduced hyperglycemia in this population hasnot been well studied. Only 3 of 45 studiesin a meta-analysis evaluating the effects ofdexamethasone measured perioperative glucose.Further, none of the studies evaluated theeffects of dexamethasone on glucose in patientswith diabetes [21]. Thus, further research isneeded to help delineate the risks and benefitsof perioperative dexamethasone use in patientswith diabetes.The combination of the surgical stress, anesthesiaand steroids may result in hyperglycemia.Hyperglycemia leads to the production ofinflammatory cytokines (tumor necrosis factoralpha, interleukin-6, interleukin-1beta). Thesecytokines further contribute to insulin resistance,potentially by interfering with signaling of theinsulin receptor and/or the glucose transporter-4receptor [22]. Further, hyperglycemia impairsneutrophil function by limiting adherence,68Diabetes Manag (2018) 8(3) A. Role of measuring A1cPoor glycemic control is associated withpostoperative complications and increasedmortality. However, the impact of glucosecontrol in the preoperative period versus theintra- and postoperative setting has been lessclear. Several studies have shown an associationbetween elevated preoperative A1c andpostoperative complications and/or mortality[23,24]. Additional studies have found anassociation between elevated perioperativeblood glucose levels and mortality [25]. Furtherinvestigation into the effects of preoperative A1cand perioperative glucose levels on postoperativemortality demonstrated that preoperative A1cis indeed an excellent predictor of perioperativeglucose control. However, when controlling foreach other, perioperative glucose control wasclearly associated with postoperative mortalitywhereas preoperative A1c was not [26]. Thus, anelevated A1c can best help by identifying patientsthat need focused attention on glycemic controlin the perioperative period. Of note, an A1c of6.5% or higher is diagnostic for diabetes [27]and the target A1c for most nonpregnant adultswith diabetes is less than 7 to 8% depending ontheir concomitant comorbidities [28]. Providersshould consider checking an A1c on any surgicalpatient with a history of diabetes if the A1chas not been assessed within the last 90 days.Screening criteria for diabetes in patients withoutknown diabetes are listed in (TABLE 1) [27].There have been no prospective randomizedtrials that have evaluated the impact ofcontrolling blood glucose prior to surgery.However, large clinical trials have demonstratedreduction in micro vascular and macro vascularcomplications with improved glycemic controlin patients with type 1 and type 2 diabetes [2932]. Patients with type 1 diabetes randomizedto intensive insulin therapy (resultant A1c7.2%) had a reduction in the incidence ofretinopathy by 76%, neuropathy by 69%, andmicro albuminuria by 34% compared with
Perioperative diabetes managementReview ArticleTable 1. American Diabetes Association Screening Criteria for Diabetes (27)All patients age 45 years; if normal repeat at least every 3 yearsPatients with BMI 25 kg/m2 ( 23 in Asian Americans) and one additional risk factor*Patients with history prediabetes should be tested annuallyWomen with history of gestational diabetes should be tested every 3 years*Risk factors: first degree relative with diabetes; high-risk race/ethnicity; history of cardiovascular disease;polycystic ovary syndrome or other conditions associated with insulin resistance; hypertension; low HDLand/or high triglycerides; physical inactivity.patients with type 1 diabetes randomized toconventional treatment group (resultant A1c9.1%). Furthermore, intensive insulin therapydecreased progression of all three micro vascularcomplications in patients that had baselineabnormalities [29]. Follow up 17 years after theintervention demonstrated 42% reduction incardiovascular disease, and 57% reduction in therisk of nonfatal myocardial infarction, stroke, ordeath from cardiovascular disease [30]. Similarly,patients with type 2 diabetes randomized tointensive glucose control with oral medicationsor insulin (resultant A1c 7%) experienced a25% risk reduction in micro vascular endpointscompared to patients in the conventional group(resultant A1c 7.9%) [31]. Follow up ten yearslater demonstrated additional risk reductionsfor myocardial infarction (15%, p 0.01) anddeath from any cause (13%, p 0.007), with evenmore substantial reductions in the group treatedwith metformin (33% reduction in myocardialinfarction, p 0.005; 27% reduction in deathfrom any cause, p 0.002) [32]. Thus, identifyingpatients with poorly controlled diabetes andaiming to improve glucoses prevents microand macro vascular complications. Based onthis reasoning and the opportunity to identifypatients preoperatively, some institutions haveprograms to identify and treat poorly controlleddiabetes preoperatively [22,33,34]. Although thelong term benefits of these programs remain tobe seen, the proportion of patients presentingon the day of surgery with a blood glucoselevel 200 mg/dl decreased from 33% to 20%at one institution after implementation of theirpreoperative program [34]. In addition, earlyresults from patients going through a similarprocess resulted in a median glucose on day ofsurgery of 151 mg/dl [35]. B. Carbohydrate loading before surgeryIn recent years, enhanced recovery after surgeryhas allowed clear fluids including carbohydrate(CHO)-rich beverages a couple of hours priorto surgery. By altering the catabolic response tosurgery that normally occurs in the fasting state,the preoperative consumption of CHO-richbeverages may reduce insulin resistance. Wanget al. found that colorectal patients randomizedto preoperative CHO had lower postoperativeinsulin resistance compared to those who werefasting or received placebo, and this appeared tobe from stimulation of the phosphatidylinositol3-kinase/protein kinase B signaling pathway[36]. CHO-rich beverages have also been shownto improve patient well-being before surgery byreducing thirst, hunger and anxiety [37]. It isless clear whether patients with diabetes will havesimilar benefits. There is concern about potentialdelay in gastric emptying in patients with diabeteswhich may increase aspiration risk, as well ashyperglycemia from the CHO load. A smallstudy comparing 25 patients with type 2 diabetesto healthy controls did not find a difference ingastric emptying, however, there was transienthyperglycemia noted in the patients with diabetesthat resolved by 180 minutes [38]. These findingsare overall reassuring; however, further study isneeded to clarify the risks and benefits of CHOloading in patients with diabetes. C. Preoperative medicationrecommendationsPatients with diet controlled diabetes do notgenerally require medications for their diabetesbefore surgery, but should have close postoperativemonitoring to evaluate for hyperglycemia relatedto the surgery, steroids, etc. For patients withtype 2 diabetes treated with oral medicationsor non-insulin injection therapy, medicationscan be given as usual the day prior to surgery,but held on the morning of surgery [39]. It isnotable that recent evidence demonstrates thatdipeptidyl peptidase 4 (DPP4) inhibitors are safein patients undergoing noncardiac surgeries [40].Further studies including cardiac and generalsurgery patients are underway.For patients with either type 1 and type 2diabetes, basal insulin therapy (glargine, levemir,degludec) is continued but at a reduced dose(often 75-80% of normal dose starting the nightprior to surgery) [22]. Prandial insulin therapy(lispro, aspart, glulisine) is given as normal the69
REVIEW ARTICLESetji, Gilmore, Freemanday prior to surgery but held on the day ofsurgery if the patient is fasting. Patients treatedwith NPH or mixed insulin should considerreducing the dose the night prior to surgery by20-25% as well as the day of surgery by 50%[22,39]. The treatment of patients that usecontinuous subcutaneous insulin infusion (CSII)pumps to control their glucoses is discussed in aseparate section.Day of SurgeryThe American Diabetes Association recommendstarget blood glucose levels of 80 to 180 mg/dlin the perioperative setting. If insulin is usedto treat hyperglycemia, the glucose treatmentgoal for most patients is 140 to 180 mg/dl, and 110 to 140 mg/dl for select patientsif this can be achieved without significantrisk for hypoglycemia [39]. These treatmentrecommendations are fairly consistent with thoseof the Joint British Diabetes Societies who alsorecommend initiating insulin therapy if glucosesare 80 mg/dl and targeting glucoses between108 to 180 mg/dl in most patients [41,42].Blood glucose testing should be completedpreoperatively and every 2 hours intraoperativelyfor patients with diabetes [22,33]. If patientexperiences hypoglycemia, intravenous dextroseshould be administered with reassessment ofglucose, more frequent glucose monitoring, andconsideration of a continual dextrose-containingIV solution during surgery (see Hypoglycemiasection for more details).Patients with hyperglycemia (glucose 180mg/dl) should be treated with subcutaneousor intravenous insulin infusion during surgery[39,42]. Patients undergoing short procedurescan often be treated with a single subcutaneousdose of correction insulin, preferably rapidacting insulin analogs (lispro, aspart, glulisine)over regular insulin because rapid acting analogswork faster to bring the glucose down and areless likely to cause hypoglycemia [22]. Criticallyill patients and those undergoing long andcomplex procedures should be treated with IVinsulin. IV insulin has a short half-life whichallows for rapid titration to achieve control ofglucoses. There is a number of paper IV insulinprotocols published. Alternatively, computerbased algorithms may more rapidly controlglucoses with less variability and hypoglycemiain glycemic control than paper protocols [43]and have been shown to be safe in the operating70Diabetes Manag (2018) 8(3)room [44]. However, the cost of these programsand available resources need to be weighed whenconsidering implementation. Patients treatedwith IV insulin need to have glucoses monitoredat least every 1-2 hours depending on the IVinsulin protocol, and perhaps more frequently ifthe rate of blood glucose fall is rapid or glucose isin the low end of the target range.Postoperative CarePatients that have required IV insulin infusionscan be transitioned to subcutaneous insulin onceinfusion rates are stable and glucoses controlled,particularly if a diet has been initiated. BecauseIV insulin has a very short half-life, thesubcutaneous insulin should be administeredprior to discontinuation of IV insulin [45].The basal infusion rate during fasting is agood predictor of basal subcutaneous insulinrequirements, however, providers often reducethe amount by 20% upon transition [46]. Forinstance, if a patient required 1.5 unit/hour ofIV insulin overnight, this would suggest a basalneed of approximately 36 units of insulin daily.However, reducing this by 20% would result ina starting basal dose of 30 units of insulin daily.Some institutions have dedicated pharmacists ordiabetes providers to help with the transition ofIV insulin to subcutaneous regimens. Inpatientdiabetes management by a specialized team hasbeen shown to reduce 30-day readmission rates,reduce inpatient diabetes cost, and improveadherence to follow up and transition of care.Further, length of stay is significantly shortenedif the diabetes team is consulted during the first24 hours of admission [47].Patients not requiring IV insulin infusionbut whose diabetes has been treated withsubcutaneous insulin, oral medications ornon-insulin injectable therapy often requirebasal insulin therapy in the hospital to controlglucoses. If baseline basal insulin requirementsare unknown, initiating basal insulin therapy at0.1 to 0.25 unit/kg/day is a good place to start[22]. Patients that are insulin sensitive (type 1,thin body habitus), elderly, or have impairedrenal function should be started on the lower endof the range. Patients that are obese or insulinresistant often need higher doses of basal insulin.Prandial insulin (starting at 0.1 to 0.25 unit/kg/day, thus 0.03 to 0.08 unit/kg/meal) is oftenrequired when patients are eating well [22].A randomized controlled trial demonstratedthat basal bolus (basal insulin plus bolus
Perioperative diabetes managementprandial insulin) therapy reduces postoperativecomplications including wound infectionscompared to those treated with only sliding scale[17]. Alternatively, basal insulin plus correctioninsulin (the Basal Plus approach) can effectivelycontrol glucoses in surgical patients in whomit is less certain how well they will eat [48]. Inaddition, a recent prospective randomized trialdemonstrated that basal insulin plus a DPP-4inhibitor can be effective in noncardiac surgicalpatients with type 2 diabetes treated at home withdiet, oral medications, or low dose subcutaneousinsulin (total daily dose of 0.4 unit/kg/day or less)[40]. Although not demonstrated in this smallstudy, it seems plausible that a combination ofbasal insulin and DPP4 inhibitor therapy mayhave less hypoglycemia and improved patient andstaff satisfaction compared to basal bolus therapy.Larger studies are ongoing to further evaluate therole of DPP4 inhibitors in surgical patients.Continuous subcutaneous insulin infusion(CSII) therapyHospitals should have standardized proceduresfor patients that use subcutaneous insulin (CSII)pump therapy [49]. Patients can either betransitioned to an off pump plan by their primarydiabetes provider prior to surgery or can continuepump therapy until they present for their surgery.Depending on the baseline level of glycemiccontrol, the basal rate the night prior to surgerymay need a reduction in rates [39], particularly ifblood glucose trends down overnight at baselineor if glucoses in the mornings are in the low tolow-normal range. However, many patients withappropriate basal rates in their CSII do not needto decrease their basal rate the night prior surgery.If their procedure is not compatible with CSII(surgery is long and complex, radiology exposureincompatible with the pump), the patient can betransitioned to intravenous insulin therapy forthe procedure with resultant resumption of CSIIonce the patient is able to manage their pump.Alternatively, a basal bolus subcutaneous regimencalculated by their current pump settings andprandial requirements can be initiated in theperioperative setting. Howe
hyperglycemia, and the management of diabetes in the perioperative period including preoperative evaluation, day of surgery management, and postoperative care. Pathophysiology of perioperative hyperglycemia There are many factors that contribute to hyperglycemia in the perioperative setting. Surgical stress increases secretion of counter regulatory
Bruce W. Bode, MD, FACE Atlanta Diabetes Associates Atlanta, Georgia American Diabetes Association. Facts and Figures. Available at: http://www.diabetes.org/ada/facts.asp. Accessed January 18, 2000. Diagnosed Type 1 Diabetes 0.5 - 1.0 Million Diagnosed Type 2 Diabetes 10.3 Million Undiagnosed Diabetes 5.4 Million Prevalence of Diabetes in the US 3
A healthy perioperative practice environment can be defined as a practice setting that is safe, healing, humane, and respectful of the rights, responsibilities, needs, and contributions of all members of the perioperative team. 1 Members of a highly functioning perioperative team
novice perioperative nurse according to that survey was at least 30,000 to 50,000. The same survey estimated the costs of orientation for an experienced perioperative nurse at 10,000 to 15,000. Perioperative nurse executives and educators need to drill down to a very fine level to determine the true costs of orientation for new employees.File Size: 1MB
Diabetes in the United States More than 29 million people in the U.S. have diabetes 8.1 million people with diabetes are undiagnosed 9.3% of the U.S. population 1.7 million Americans aged 20 years or older were newly diagnosed with diabetes in 2010 Every 19 seconds, someone is diagnosed with diabetes
Clinical Diabetes. 2017 Jan; 35(1)51-54. Speight J, Conn J, Dunning T, Skinner TC, Diabetes Australia. Diabetes Australia position statement. A new language for diabetes: improving communications with and about people with diabetes. Diabetes Res Clin Pract 2012 Sep; 97(3): 425- 31.
Type 2 Diabetes Type 2 diabetes, which used to be called adult-onset diabetes, can affect people at any age, even children. However, type 2 diabetes develops most often in middle-aged and older people. People who are overweight and inactive are also more likely to develop type 2 diabetes. Type 2 diabetes usually begins with insulin resistance—a
TABLE 57-3. Proposed Classification System for Diabetes in Pregnancy Gestational diabetes: diabetes diagnosed during pregnancy that is not clearly overt (type 1 or type 2) diabetes Type 1 Diabetes: Diabetes resulting from β-cell destruction, usually leading to absolute insulin deficiency a. Without vascular complications b.
The group work is a valuable part of systematic training and alerts people to other training opportunities. Most have been on training courses provided by a range of early years support groups and charities and to workshops run by individual settings. Some have gained qualifications, such as an NVQ level 3 or a degree in child development and/or in teaching. Previous meetings have focused on .
