Conflict of interest Type 1 diabetes >20 years - age 23 Pens: -Aspartate insulin (Novorapid): GM human; 3 X 12 units -Glargine (Lantus): GM human: 36.

Sweet and sour: Intraoperative glycaemic control

Dave Story•Head of Research, Department of Anaesthesia, Austin Health;•A/Prof, Department of Surgery, University of Melbourne•Chair, ANZCA Trials Group

Conflict of interestConflict of interestType 1 diabetes >20 years

- age 23

Pens:

-Aspartate insulin (Novorapid): GM human; 3 X 12 units

-Glargine (Lantus): GM human: 36 units nocte

-BSL – Glucometer 5 seconds: digital + log

Gerich, Am J Med, 2002

Topics:Topics:

• New role for HbA1c

• New insulins

• Perioperative glucose control

Frequency perioperative diabetes Frequency perioperative diabetes

REASON study

4,150 older inpatients

23 hospitals ANZ

22% diabetes, 30-day mortality 5% (OR 1.0)

-27% IHD (20% all)

-26% CRI (16% all)Story et al, Anaesthesia, 2010

Diabetes diagnosisDiabetes diagnosis

• Random BSL >11mmol/L• Fasting BSL ≥ 7 mmol/L• OGTT 2hr BSL >11mmol/L

– Diabetes likely – Diabetes unlikely – Impaired glucose tolerance, >5.5 mmol/L

Diabetes Australia + RACGP,

Diabetes Management, 2009

Diabetes “severity”Diabetes “severity”

Using haemoglobin A1C: HbA1c “A1C”

Hb + glucose irreversibly attached to beta chain

A1C - 3 months; <30 days 50%, 60 to 120 days 25%

A1C Mean BSL

6% 7.5 mmol/L

7% 9.5 mmol/L

8% 11.5 mmol/L

9% 13.5 mmol/L

10% 15.5 mmol/L

Burtis et al, Tietz Textbook Clinical Chemistry, 2006

Not acute Type 1RBG > 11 mmol/L diagnostic

Diabetes Care, 2009

Endorsed by Diabetes Society of Australia

A1C ≥6.5% DM, 6.0% to 6.4% IntoleranceA1C ≥6.5% DM, 6.0% to 6.4% Intolerance

Diabetes Care, 2009

Medical Journal of Australia 2011

Flinders 200911% (262/2360) undiagnosed666 surgical patients52 (8%) known diabetes54 (8%) unknown diabetes

Surgery, ASurgery, A1C1C and infection and infection

490 diabetic patients, non-cardiac

VA Conneticut

Median age 72, median A1C 7.3%

A1C < 7.0%, n= 197, infection 12%

A1C ≥ 7.0%, n= 293, infection 20%

Adjusted OR

A1C ≥ 7.0%, infection OR 2.1 (1.2 to 3.7)

Dronge et al, Arch Surg, 2006

Ann Thorac Surg, 2009

New InsulinsNew Insulins

Killen et al, Anaesth Intensive Care, 2010

Insulin PumpsInsulin Pumps

• Basal rapid acting infusion + boluses

Killen et al, Anaesth Intensive Care, 2010

HypoglycemiaHypoglycemiaVariation between and withinUS mg/dl = mmol/L X 18 approx 20

200mg/dl = 11.1 mmol/L (approx 10 mmol/L)

Reference Range: 4 mmol/L to 6 mmol/L

3 mmol/L – sympathetic – sweating, hunger

2.5 mmol/L – altered CNS: confusion, diplopia

Eventually coma, deathService, NEJM, 1995

Perioperative diabetesPerioperative diabetes• Limited evidence

Glister + Vigersky, Endocrinol Metab Clin N Am, 2003

• Ask patient:“What and when” - sugar and insulin

• Three parts:-Basal: glargine – avoids ketosis (cf GIK)-Nutritional – rapid (W/H)-Corrective –rapid s/c or IV regular

Assundi + Calles-Escandon, J Hosp Med, 2007Killen et al, Anaesth Intensive Care, 2010

Dumb things with insulinDumb things with insulin

• Forget to take it• Take twice

– short – long

• Take wrong one• Take too much• Eat too much for usual dose• Eat too little for usual dose

Unusual and/or stressful situations

Insulin pumpsInsulin pumps

Beware: Technology + no underlying long acting

Options:• IV regular infusion at basal rate (day surgery)• Continue with pump if confident• Convert to s/c rapid + glargine

Assundi + Calles-Escandon, J Hosp Med, 2007

Killen et al, Anaesth Intensive Care, 2010

Perioperative diabetesPerioperative diabetes

Measure

the

blood sugar

What BSL?What BSL?

Aim: 8 mmol/ L (5 to 10 mmol/L)

NICE-SUGAR: 6000 ICU patients

4.5 to 6.0 mmol/L (tight) vs <10 mmol/L (usual)

90 day mortality, Tight control surgical OR: 1.31

Hypos 6.8% vs 0.5%

NICE-SUGAR Investigators NEJM, 2009

Hypo…how much dextrose?Hypo…how much dextrose?• Mild to mod: 3 to 5 mmol/L; severe < 3 mmol/L

• Don’t over treat: target 8 mmol/L (5 to 10 mmol/L)

– Dextrose 5% = 5 g/100ml

– Dextrose 50% = 50 g/100 ml = 5g/10 ml

IV push

• BSL 3-5 Dose = 0.1 g/kg 2ml/kg 5% dextrose

• BSL < 3 Dose = 0.15 g/kg 3ml/kg 5% dextrose

Can’t remember = 150 ml 5% Dextrose (7.5g)

= 15 ml 50%Assundi + Calles-Escandon, J Hosp Med, 2007

You can drink D5WYou can drink D5W

…but the taste isn’t great

Why is the patient hypo?Why is the patient hypo?

• Poor management: eg delay• Mistake in insulin or intake?• Is the problem fixed?

– beware duration too much long-acting• Beware insulin infusions

Most likely…hyperglycemiaMost likely…hyperglycemia

My glucometer on Christmas day…My glucometer on Christmas day…

Most likely…hyperglycemiaMost likely…hyperglycemia• BSL > 10 mmol/L • Hours: unpleasant hyperosmolar, dehydrated• Don’t over treat; target 8 mmol/L (5 to 10 mmol/L)• 80/total daily insulin = 1 unit effect mmol/L BSL• Me: 72 units / day

80/72 = 1.1 mmol/L for 1 unitAdult rule of thumb: BSL - 8 = IV regular insulin

OR S/C rapid

Glister + Vigersky, Endocrinol Metab Clin N Am, 2003

Then 15 minutes later…Then 15 minutes later…

Measure

the

blood sugar

PostopPostop

• Physicians

• Three parts (alternative to insulin infusion) • 0.5 units / kg / day (conservative start)

-Basal: glargine 0.25 units / kg / day-Nutritional –rapid s/c 0.25 units / kg / day-Corrective – rapid s/c

• RABBIT 2, Diabetes Care 2011

Assundi + Calles-Escandon, J Hosp Med, 2007

Higher A1C less tolerant of lower glucoseHigher A1C less tolerant of lower glucose

Egi et al, Crit Care Med, 2010

AcclimatizationAcclimatization

Concluding thoughts…Concluding thoughts…Balance of probabilities:• A1C in all coronary + vascular patients• ?A1C in others eg 70+

• No DM + A1C >6% - med review – risks• A1C >8% +/- DM - med review

Research: A1C in ANZ populations: complications :RCT usual care vs A1C < 7.0 preop

Measure the blood sugarMeasure the blood sugar

Concluding thoughts…Concluding thoughts…• No evidence for very tight control in OR• Aim: 8 mmol/L (Range: 5 to 10 mmol/L)• Give basal• W/H rapid • Don’t overreact• Use IV regular or s/c rapid to correct• Beware pumps• Antiemetics• D5W is our friend• Endocrine involvement for O/N stay

Measure the blood sugarMeasure the blood sugarAhmed et al, Anaesth Analg, 2005

You forgot to measure the blood sugar?!?

ThanksThanks