lester sherington kyper perioperative

7/28/2019 Lester Sherington Kyper Perioperative

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Perioperative Care For theGeneral Surgical Patient

Linda Lester, MD- OHSURob Kyper, MD Southwest Washington Medical Center

Sarah Sherington, PharmDSouthwest Washington Medical Center


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Pre-operative issues- Dr. Lester

Intraoperative glycemic control- Dr.Kyper

In-Patient management of diabetes in

the hospital- Dr. Sherington


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Pre-operative Objectives:

Pre-operative evaluation of the diabeticpatient

Assessing Pre-operative glycemic control Does pre-op glycemic control correlate with

outcomes

Recommendation for glucose management pre-op

How common is unrecognized diabetes


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Pre-operativeRecommendations for

Patients with Diabetes

Goal: Maintain euglycemia whileminimizing risks for hypoglycemia andother drug related complications

Decrease length of stay and risk of infections


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Patients with diabetes:

what pre-operative assessment is important?

Document the following Type of diabetes

L ength of time sincediagnosis

Current management Current glycemic control

HgBA1c

Glucometer dta

Presence ofcomplications

Neuropathy

Nephropathy

Retinopathy

Autonomic neuropathy increase risk of post op gastroparesis

and urinary tract infection


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Why is pre-op glycemic control

important?

Poor glycemic control

Increases dehydration and electrolyteabnormalities

Impairs collagen formation and decreasessurgical wound strength

Increases risk of complications

Medications for diabetes managementassociated with risks


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Can patients stay on theirpre admission therapy?

Answer: It depends on the

patient, the type of surgeryand which therapy they are

on


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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


9/58Copyright restrictions apply.

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

A Comparison of Matched Metformin andNonmetformin Treated patientson Continuous Outcome Variable


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Other oral agents? Oral Agents

TZDs- rosiglitazone orpioglitazone

Used to improve insulinsensitivity

Sulfunylureas-glipizide,glyburide or glimeperide Insulin secretagogues,

non glucose dependent

DPP-4 Inhibitors Sitagliptin (Januvia)

Work to slow foodabsorption, enhanceinsulin release inglucose dependentmanner

PotentialComplications

Increased risk offluid retention andhypoglycemia

Increased risk ofhypoglycemia

No known risks


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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 45mg/dL, patient confused, responded to IV

glucoseReason for hypoglycemia ?

On going use of glyburide


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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


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Management of Type 1 Diabetes prior toMinor Surgery Procedures

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 asindicated

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.

Patients on continuous

insulin infusion (insulin pump)

continue with basal rate

no bolusshould have hospital

guidelines on use of personal

insulin pumps


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Preoperative management of patients

with type 2 DM

Check HgBA1c prior tosurgery

Hold oral agents on dayof surgery

Check fasting bloodglucose

If less than < 180 no useshort acting insulin forcorrection

If greater than 180,consider insulin infusion

Check HgBA1c and fasting

blood glucose Hold oral agents on day of

surgery Patients with fasting blood

glucose < 180 of intermediate insulin

in am Give normal dose of

glargine

Patients with fasting bloodglucose > 180 considerinsulin infusion

Non insulin treated patient Insulin treated patient


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Clinical Example 56 y/o male, no prior history of medical

problems

Involved in MVA requiring emergencysurgery for open femoral fracture

POD # 3 routine AM glucose elevated at230 mg/dL

Is this stress or hospital associated hyperglycemia?

What are the implications?


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What about undiagnoseddiabetes?

Prevalence of DM in hospitalized patients- 12-26%

Prevalence of inpatient hyperglycemia- 38% (chart review of 1886 medical and surgical pts at

community teaching hospital)

1/3 with newly discoveredhyperglycemia20-30 % ofpatients with diabetes are undiagnosed

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.

R l ti hi b t


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Relationship betweenperioperative glucoseand postoperative infection

Stress or new hyperglycemia associated

with higher in hospital mortality rates(16%) compared with prior history ofdiabetes


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Screening adults for diabetesprior to surgery

Pilot study for 2 weeks

261 patients evaluated

200 without documenteddiabetes

Mean CBG lower in nonDM

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


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Using POC HGBA1c and CBG Measurements

4 week pilot oncardiovascularintervention unit

146 pts without DM

34 patients with DM

Mean fasting CBG

No DM=109

DM=145

HgBA1c correlates butwith lower fasting CBG


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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

Importance of unrecognized diabetes


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Identifying At risk Patients

Hyperglycemia from poorly controlled diabetes or inpatients with unrecognized diabetes can increaseshospital related morbidity and mortality

Elevated HgBA1c indicates need for post hospitaltherapy change in patients with diabetes increasesthe likelihood of needing therapy after hospitalization

Must have routine monitoring of glucose levels andHgBA1c to identify patients

Recommend CBG monitoring on all surgical patients for first24-72 hours Add HgBA1c to admission labs for all patients with diabetes add for patients that have two CBGs > 140


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Intra-operative GlycemicControl

Robert Kyper MD

Columbia Anesthesia GroupOctober 12, 2007


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Dr. Evil Says.


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History of Glycemic Control

Anesthesiologist goals:

Avoid hypoglycemia & severe

hyperglycemia No point of care testing

Insulin given IV or SQ to few patients


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Textbook TrainingAnesthesia and Co-existing Disease, 4th

Edition, Stoelting & Dierdorf (2002)

Consensus that IDDM patientsundergoing surgery be treated w.insulin

NO evidence that close glucose controlin relatively brief intraoperative periodbenefits diabetic patients.


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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 basedphysicians including anesthesiologists haveNOT changed their practices in regards toglycemic control


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Anesthesia Literature

Numerous studies, Cardiac surgery

Numerous studies, ICU pts. (the sick)

Injured/ischemic brains

Notable lack of data for Ortho./ General


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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 areinsulin deficient

5. Create and implement a hypoglycemiaprevention and management protocol


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Day of Surgery: How sweet it is.

Data from: Vivek K. Moitra, VK, Jason Greenberg, J, & Sweitzer, BJ (2005).

Hyperglycemia on the Day of Surgery. ASA Abstracts

Preoperative Blood Glucose Readings


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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


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Barriers

D5 containing fluids

Dexamethasone (steroid) PONV ppx

Stress dose steroids

Insulin availability

Glucometer availability

Hemodynamic management

Duration of surgery


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Metformin

Risk of lactic acidosis Rare, yet mortality of 50%

Probably benefits out weigh risks Does not increase in-hospital mortality

after cardiac surgery Duncan, Anesth Anal 2007;104:42-50

Complications were lower Less: prolonged intubation, infection, overall

morbidities


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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 One to One pt. / provider care

Manage Antibiotics, temp., glycemic control


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Insulin Pumps

Basal insulin need

Leave in running if

possible May need to remove

for positioning, orsurgical field

If removed, insulininfusion for longersurgery


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Guidelines - Elective Surgery

CBG 3hr.) CBG 200-349 treat,

and Anesthesiologistdiscussion with

Surgeon, (proceedor delay)

CBG 350,postpone surgery

until CBG improved


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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 steroidgiven) check Q1hr


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Avoiding Increases in BloodGlucose

Avoid boluses of D5containing IV fluid

Pre-op. nursesHanging 500 mlbags of D5LR More readily

identifying IVF as

something otherthan LR

Reducing the dose

Dexamethasone;avoid or reducedose

Consider insulininfusion postoperatively, if given

Alternatively NPHinsulin dose andsliding scalecoverage


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Insulin Administration in theOR

How aggressive? Keep glucose < 180

4 Column infusion

IV boluses Useful for short

cases in place of drip

Useful to augmentinfusion in longercases


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Transitions

Considered problematic for manyaspects of patient care, including

glycemic control Insulin infusions to PACU, possibly to

floor

Coordination with glycemic control team


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Peri-operative Care for the

General Surgical Patient:The Pharmacists Role

Sarah L. Sherington PharmD

Glycemic control/surgical services

Southwest Washington MedicalCenter


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Management of the Surgical PatientPre operative

Instruction sheet given to all diabetics

Hold oral diabetic medications day of surgery

Give full dose of glargine (Lantus) the nightbefore surgery

Give half usual dose of NPH or regular insulin dayof surgery

In order to reduce complications such as infection,you may be given insulin during yourhospitalization, even if you are not currently usinginsulin.


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Identifying The DiabeticPatient

Surgery schedule identifies knowndiabetic patients

Scheduling form changed Diabetic yes/no

Blood glucose on all patients admitted

for inpatient surgery unlessdocumented fasting blood glucose lessthan 130mg/dl


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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 usingthe 4 column infusion protocol

Post operative management Correction dose insulin orders using insulin aspart

Insulin infusion


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Glycemic Control Pharmacist

Identifies all surgery patients who arediabetic or have a recorded elevated bloodglucose

Surgery patients include all patients admittedto the two surgery floors or medical/surgeryfloor not followed by a PCP and all CABG

patients transferred from CCU Resource for physicians and nurses with

patients with poor glycemic control


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Inpatient Management ofHyperglycemia

Hold oral diabetic medications

Order bmp for all patients on metformin

Intravenous insulin therapy Best therapy for patients with a critical illness,

changing status or severe hyperglycemia

Scheduled insulin

Basal and prandial/nutritional insulin

Supplemental insulin

Increase in daily insulin requirement attributed toillness, stress or treatment


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PACU: Percent Glucose Readings by Range

January 2007 - June 2007

0.01.2

0.0 0.0 0.01.62.5

0.00.0 0.0

77.2

80.369.6

74.4

79.7

67.4

10.1

15.012.2

15.5

23.4

15.6

0

20

40

60

80

100

Jan07

Feb

07

M

ar07

Apr07

M

ay07

Jun07

Percent

< 40 mg/dl 40 - 69 mg/dl 70-180 mg/dl >= 200 mg/dl

70-180 mg/dl

>=200 mg/dl


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PACU: Average Blood Sugar

January 2007 - June 2007

150.0148.8

151.7

154.7

154.2

168.3

145

155

165

175

185

195

Jan07

Feb07

Mar07 Apr

07Ma

y07

Jun07

Average(mg/dl)


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Average Length of StayAve Length of Stay (ALOS) Comparison - Surgery Patients with and without Insulin

0.00

2.00

4.00

6.00

8.00

10.00

12.00

Month

ALOS

W/Insulin

W/O Insulin

Linear (W/Insulin)

Linear (W/O Insulin)

W/Insulin 9.70 8.44 8.22 8.31 9.42 8.59 8.59 8.09 9.59 9.36 7.88 8.28 7.77

W/O Insulin 3.79 3.93 3.79 3.93 4.57 4.06 3.93 3.61 4.15 3.76 4.04 3.80 3.49

JUN-

06

JUL-

06

AUG-

06

SEP-

06

OCT-

06

NOV-

06

DEC-

06

JAN-

07

FEB-

07

MAR-

07

APR-

07

MAY-

07

JUN-

07


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Questions?

lester sherington kyper perioperative

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