Guidelines for the management of Diabetes in the Perioperative period QEII Hospital June 2012.

The purpose of this guideline is to standardise peri-operative management of Diabetes in QEII hospital & facilitate such management by medical staff. It is clear that peri-operative hyperglycaemia is associated with increased LOS and greater peri-operative complications & mortality. No clear, specific guidelines exist in the management of diabetes in the peri-operative period. Following is a recommendation based on review of the available literature. Professionals who are experienced in managing diabetes may choose to use alternative regimens as circumstances vary. It will be updated as more evidence becomes available.

Pre-operative evaluation
Type 1 or 2 Diabetes Long term complications Baseline glycaemic control HbA1c, frequency of monitoring, range of blood glucose at home Hypoglycaemia frequency, timing, awareness & severity Treatment Oral hypoglycaemic agents Insulin type, timing, doses Compliance Type of surgery Major or Minor. For the purposes of these guidelines all major surgery involves an overnight stay & minor surgery are day procedures. Timing of surgery Time of NBM Type of anaesthetic GA/Epidural/Local

Pre-operative basic lab investigations ECG

Renal function HbA1c (>9% consider Endocrine consult pre-op)

Glycaemic targets
Avoidance of hypoglycaemia(<4mmol/l) & hyperglycaemia ADA targets for general hospitalised patients Fasting <7.8mmol/L & Random <10mmol/L. Reasonable to aim for a majority of BSL < 10 - 11mmol/L Intravenous Insulin infusion hourly NBM postoperative patients 2-4 hourly Short stay/day surg procedures 2 hourly

Monitoring of BSL

Postponing surgery
Surgery should be postponed in patients with significant complications of hyperglycaemia such as severe dehydration, ketoacidosis, and hyperosmolar nonketotic states. It is acceptable to proceed with surgery in patients with pre-operative hyperglycaemia but with adequate long term glycaemic control (HbA1C) In patients with chronic poor glycaemic control (HbA1c > 9%), seek Endocrine opinion & optimise control prior to surgery. For emergency procedures it is appropriate to start intravenous insulin infusion & proceed with surgery. Ensure Endocrine opinion obtained as an inpatient.

General Recommendations
All patients with diabetes should be scheduled to have their surgery as early as possible in the morning to minimise disruption of their diabetes management whilst NBM. Due to the possibility of hypoglycaemia whilst fasting, patients should not drive themselves to the hospital. They should bring their usual medications & insulin with them.

Type 2 patients on Diet alone

Usually do not require any therapy peri-operatively. If BSL persistently > 11mmol, small doses of sliding scale insulin or oral hypoglycaemic agents, if eating.

Type 2 diabetes on Oral Hypoglycaemic Agents

Continue usual dose until the day before surgery Withhold oral hypoglycaemic agents on the morning of surgery Oral hypoglycaemic agents can be restarted once patients resume eating Most patients with good pre-operative control will not require insulin for short surgical procedures Withhold Metformin until patient eating/drinking well & documentation of normal renal function (usually 24 hours post major surgery) Withhold Metformin for 48 hours following iodinated contrast & document normal renal function before restarting. Some guidelines suggest withholding Metformin therapy for 48 - 72hours prior to surgery. No specific trials support this & risk of ensuing hyperglycaemia prior to a surgical procedure is greater. Non insulin treated patients who take more than one oral agent, undergoing major surgery, may require Insulin/Dextrose infusion for the first 24 hours especially, if their blood glucose is > 11 mmol. Low threshold for commencing basal/bolus insulin regimen if BSL > 11mmol consistently, especially if preoperative control inadequate (HbA1c>8%). See below on how to start basal bolus insulin therapy.

Type 1 or Insulin treated Type 2 Diabetes

All patients on insulin should be treated the same way regardless of the type of diabetes they have. Basal metabolic needs require of the patients total insulin dose even if not eating hence, patients will need insulin even if nil by mouth Insulin treatment is mandatory in Type 1 to prevent DKA Poor control may require IV insulin infusion irrespective of home treatment. Recommended dose reductions for long acting Insulin (Lantus & Levemir) vary between 50% to no dose reduction. Reasonable to reduce dose to 75% in most circumstances. Reasonable to use full basal dose in poorly controlled patients. If patients are receiving insulin on the morning of minor procedure it should preferably be administered after the patient is in the short stay unit to avoid hypoglycaemia en route. Sepsis & stress of procedure can change insulin requirements. Antibiotics do not affect insulin treatment unless it precipitates renal impairment.

Minor Surgery Early morning procedure (NBM from midnight):

Delay usual morning dose until after the surgery. Give usual dose after procedure & when eating

Morning procedure where Breakfast & lunch are likely to be missed (NBM from midnight)
Once a day Lantus(previous night or morning of surgery):- Give ~75% of dose QID Insulin:- Omit short acting insulin on the morning and afternoon of surgery, Give ~75% of long acting insulin (Lantus or Levemir) BD mixed insulin (Novomix 30/Mixtard 30/70 ):- give 1/2 of their usual total morning dose as an intermediate acting insulin (e.g. Novomix 30 or Mixtard 30/70 usual morning dose 30 units give 15 units of protophane in the morning)

Afternoon procedure where early morning or usual breakfast given

QID insulin: - Give ~75% of long acting Insulin. Give short acting insulin with early morning or usual breakfast. Dose reduction maybe required if having light breakfast. BD Insulin (Novomix 30 or Mixtard 30/70):- Give 1/2 of morning dose of mixed Insulin with breakfast.(e.g., Novomix 30, usual morning dose 30units, give 15 units with breakfast)

Major Procedure T1 or Insulin treated T2

An insulin/dextrose infusion is the best way of maintaining euglycaemia postoperatively especially in those previously treated with insulin, poorly controlled prior to admission, receiving more than one type of oral hypoglycaemic medications & who are not capable of resuming their usual diet & treatment(major surgery). Intravenous insulin/dextrose infusion is required for patients undergoing major surgery. Half life of IV insulin is short ~ 5minutes Hourly blood glucose monitoring is necessary whilst on the insulin infusion Give 5% dextrose IV at the rate of 100mls/hour (5gms of glucose/hour), for basal energy requirements, to prevent hypoglycaemia, ketosis & protein breakdown. Acceptable alternatives are 3% dextrose with 1/3NaCl or 4% dextrose with 1/5th NaCl. Rate should be reduced in patients with history of fluid retention/CCF (e.g. 60 - 80mls/hour). Patients with diabetes with normal renal function & potassium levels require10 - 20mmol of potassium added per litre of dextrose solution. Insulin infusion should be continued until patient resumes eating postoperatively Basal/bolus insulin regimen is preferable once, the patient has resumed eating Once oral intake is tolerated, IV can be changed to SC Insulin give SC insulin before stopping IV. Failure to overlap SC insulin prior to cessation of IV insulin will result in rebound hyperglycaemia. Long acting analogues such as Lantus & Levemir need to be given 2 hours before cessation of IV Insulin. Rapid acting Insulins (Novorapid, Apidra & Humalog) can be given before meals with IV insulin stopped at the same time. Actrapid needs to be given 30 minutes before meals & cessation of IV insulin. If the patient normally injects Lantus at night time & is changing from IV to SC insulin in the morning, 1/3 of the Lantus can be given in the morning along with the usual rapid acting insulin. Usual dose of Lantus given at night time. Sample Initial insulin infusion rates for adults BSL 0 5 mmol/L 5.1 7 mmol/L 7.1 10 mmol/L 10.1 15 mmol/L 15.1 20 mmol/L >20 mmol/L Insulin (units/hour) 0, treat hypoglycaemia, recheck in 15 mins 0.5 units/hour 1 unit/hour 2 units/hour 3 units/hour 4 units/hour

This rate may not be appropriate for all patients & needs to be reviewed regularly & adjusted accordingly. For patients already on SC insulin treatment at home, indication of their requirements can be obtained by total usual insulin requirement divided by 24.

Place of subcutaneous sliding scale

Subcutaneous sliding scale approach is reactive (administered after hyperglycaemia has occurred), problematic and should be avoided. It should never be the sole insulin/diabetes regimen. Administering subcutaneous sliding scale in addition to basal or basal/bolus insulin regimen is acceptable & in that instance is referred to as supplemental/correctional insulin. Recommended supplemental insulin doses are on the back page of current Queensland Health Insulin subcutaneous order & blood glucose record.

Basal/bolus Insulin regimen for insulin naive patients

0.5 Units/Kg body weight is the total daily dose. Elderly patients & patients with renal impairment may require lower doses - 0.2 to 0.3 units/kg. 50% of this dose is for basal requirements & the other 50% divided into 3 doses are given as bolus before main meals. It is best to keep basal insulin dose to < 20 units to start with in insulin naive patients, and then titrate as necessary. Give only basal dose if patient is NBM. Add bolus insulin dose when patient is eating > 50% of their meals.

Bowel Preparation for Colonoscopy

Oral hypoglycaemic agents should be withheld Patients with unstable diabetes, poorly controlled diabetes & on large doses of insulin should be admitted for insulin/dextrose infusion during bowel preparation For well controlled patients on basal/bolus insulin therapy, reduce rapid/short acting insulin by 50% & administer 75% of long acting insulin. Alternatively all rapid/short acting insulin can be omitted & basal insulin continued at 75% 100% of dose. For patients on BD pre-mixed insulin, reduce both doses by 50% 2 hourly BSL testing is necessary Extra glucose added to clear fluids/jelly if BSL< 5mmol. Avoid diet jelly & diet drinks unless BSL consistently > 10mmol.

TPN/NG Feed
Dislodgement of feeding tube, discontinuation of feeds, interruption of feeds for diagnostic testing/medications and cycling of enteral feeds with oral intake in patients with inconsistent appetite all pose difficulties in management of diabetes with insulin. For patients on TPN, best to start on insulin infusion for at least 24 hours for estimating insulin requirements. Aim to convert to once or twice a day Lantus. For patients on NG feeds, it is important to decide whether continuous or bolus feeds are required. Again best to start on insulin infusion (if insulin requirements are not known) & then transfer to once/twice day Lantus.

In case of intermittent NG feeds once a day Lantus with bolus rapid/short acting insulin may be necessary. Changes in insulin doses must precede changes to feeding regimen, otherwise results in hypoglycaemia. Contact Endocrinologist for advice.

Patients not known to have Diabetes

Patients not known to have diabetes previously, who have high BSL levels in the post-operative period, should be treated similar to having diabetes. If the HbA1C is > 7%, they have had undiagnosed diabetes before surgery, which needs to be evaluated (by GP or Endocrinologist, if requiring insulin in hospital). Do not assume that it is a stress response & it will resolve post-operatively.

QEII Contacts
Dr. Shanthi Kannan Endocrinologist contact switch Diabetes Educator Ext 6869.

References
1. Randomised study of Basal-Bolus Insulin Therapy in the inpatient management of patients with Type 2 Diabetes undergoing general surgery (RABBIT 2). Diabetes Care, Vol 34, Feb 2011, P-256 2. Standardised glycaemic management and perioperative glycaemia outcomes in patients with Diabetes mellitus who undergo same-day surgery. Endocrine Practice, Vol 17, No. 3, May/June 2011. 3. Society of ambulatory Anesthesia consensus statement on perioperative blood glucose management in Diabetic patients undergoing Ambulatory Surgery. Anesthesia Analgesia, Dec 2010, Vol 111, No. 6. 4. Prevalence and clinical outcome of hyperglycaemia in the perioperative period in noncardiac surgery. Diabetes Care, Vol 33, no. 8, August 2010. 5. Perioperative glucose control in the diabetic or nondiabetic patient. Southern Medical Association, 2006, March 1. 6. Perioperative Management of Diabetes. American Family Physician, Vol 67, Issue 1, Jan 2003. 7. An update on perioperative management of Diabetes. Archives of Internal Medicine.Vol 159, Nov 8, 1999.

8. Perioperative management of Diabetes mellitus. UpToDate, accessed March/April 2012. 9. Standards of medical care in Diabetes. Diabetes Care Jan 2012. 10. Long-term Glycemic control and postoperative infectious complications. Archives of Surgery. 2006; 141:375-380. 11. Perioperative Diabetes Management Guidelines, Australian Diabetes Society, May 2011. 12. Management of Hyperglycaemia in Hospitalized Patients in Non-Critical Care Setting: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab, January
2012, 97(1):1638