Perioperative Glycemic Control in Solid-Organ Transplant Patients Frances Lee 1 , Sulay Shah 2 , India Gaines 3 , Stephanie Preston 4 Jaskirat Dhanoa 1, Tina Thethi 2 , Anil Paramesh 3 1 Tulane University School of Medicine, 2 Department of Endocrinology, Tulane University School of Medicine, 3 Department of Surgery, Tulane University School of Medicine, 4 Department of Surgery, U.T. Southwestern Background Methods Results Adjusted Glycemic Control Algorithm Conclusions & Future Directions Acknowledgements This project could not be possible without the coordination and cooperation of the surgical staff, endocrinologists, pharmacists, and nurses at Tulane University. To date, there is no consensus or the standard of care for transplant dysglycemia throughout the surgical continuum, especially as hyperglycemic medications can complicate their hospital course. Transplant dysglycemia impacts post-operative recovery through increasing rates of complications, graft function abnormalities, graft rejection, and prolonging length of hospital stay. Current literature for the transplant population dysglycemia is remarkably limited at the face of these challenges. Due to the short- and long-term consequences of peri-operative dysglycemia, it is imperative to examine the current epidemiology & management of postoperative hyperglycemia. We further designed adjusted glycemic control algorithms as part of our quality improvement project to address our findings. Results Discussion Pt with previously diagnosed DM Pt is on home insulin, but not on 70/30 BASAL INSULIN LANTUS/GLAR GINE: 50% of home dose, One time NPH: 2/3 of home dose, One time LEVEMIR/DETE MIR: 50% of home dose, One time CORRECTIONAL SCALE INSULIN HUMALOG (lispro): Low, Medium, High dose Pt is on home insulin AND on 70/30 BASAL INSULIN GLARGINE (LANTUS): 25% * TDI CORRECTIONAL SCALE INSULIN HUMALOG (lispro): Low, Medium, High dose Pt is not on insulin or on 70/30 CORRECTIONAL SCALE INSULIN HUMALOG (lispro), Low dose Post-Operative Blood Glucose If BG 140-220 On Home Insulin BASAL, Full dose of Home Insulin LANTUS (Glargine) NPH LEVEMIR Correction Insulin HUMALOG, Low dose, medium dose, high dose Not on Home insulin Correctional Insulin, Adjust in 24 hours HUMALOG (lispro), Low dose If BG > 220 x 2 1) Start Insulin drip If on Home Insulin: Algorithm 3 If not on Home Insulin: algorithm 2 2) Lantus 0.25 units/kg of Body Weight 3) Discontinue Home or Other Insulin Regimen (automatic) 4) Consult Endocrine Figure 5. Pre-operative Glycemic Control Algorithm is based on patient history and home medication regiment Figure 6. Post-operative Glycemic Control A lgorithm is based on immediate post-operative blood glucose readings Transplant dysglycemia remains a challenge throughout the surgical continuum with implications on complication rates and length of hospital stay. We propose interventions that optimize insulin regiments pre- and post-operatively and define the parameters that would initiate Endocrinology consults. We will prospectively collect and analyze our data to identify degree of post-operative hyperglycemia, rate of complications, and length of stay to understand the impact of our protocol. Figure 4. Rate of infections, rejection, and endocrine consults for OLT and KT patients. Of note, over 20% of our patients had an infection during their hospital stay. Figure 3. Percent of patients receiving insulin through various modes for the first post- operative week. Lowest percent of patients on insulin therapy occurred on POD7; highest percent of patients on insulin therapy occurred on POD2. 0 10 20 30 40 50 60 70 80 90 1 2 3 4 5 6 7 8 Basal 2.2 3.65 8.3 10.58 12.94 9.4 10.5 5.8 IV Insulin 11.2 8.5 8.3 4.7 4.7 3.5 1.1 1.1 Correction Scale 6.7 20.7 21.42 22.35 17.6 17.6 16.4 11.7 No Insulin 79.77 67.07 61.9 62.35 64.7 69.4 71.7 81.1 Percent of cases 0 1 2 3 4 5 6 7 Figure 2. Percent of patients with blood glucose (BG) greater than 180 for the first post- operative week. With no reported incidences of hypoglycemia in our data set, the highest rates of hyperglycemia, defined by the ADA as blood glucose >180, occurred on post-operative day 0 and 1, 54% and 60%, respectively. Figure 1. Types of solid-organ transplants conducted by percentage. KT = Kidney Transplant; OLT = Orthotopic Liver Transplant; KP = Kidney Pancreas Transplant; SLK = Simultaneous Liver Kidney Transplant. Of note, about 30% of all patients had pre-existing DM. KT 76% OLT 19% KP 2% SLK 3% Other 5% 16.47 5.88 2.35 18.82 0 2 4 6 8 10 12 14 16 18 20 Wound infection Other Infection Acute Graft Rejection consult Percent of cases We conducted a retrospective analysis of 94 transplant recipients over a 6-month period (2015-2016). Data collected include demographic information; pre-operative A1C; post-operative blood glucose minimum, maximum, and median (day 0-7); mode of insulin delivery; post-operative infection; endocrine consultation during hospital course; and length of stay. • Given that the highest rates of hyperglycemia occurred on POD0 and POD1 while insulin therapy was utilized most on POD2, we observed how clinical inertia can lead to delayed use of insulin therapy. Moreover, over a fifth of our patients acquired an infection, which may be associated with post-operative dysglycemia. Endocrinology, which could mitigate dysglycemic events, was consulted in less than 20% of all cases. • With our new algorithms, we project that 28%, as opposed to 13.4%, of post- operative transplant recipients will be treated with an insulin drip. We hope that our pre-operative dysglycemia protocol will prevent post-operative glycemic deviation. Through stepwise improvements, initially with a blood glucose goal of less than 220, we hope to achieve a target blood glucose of less than 180 in order to abide by the ADA guidelines for glycemic control. 54.5 60.2 50.9 38.9 36.6 30.8 35.5 40.5 0 10 20 30 40 50 60 70 Percent of cases with BG >180 Post-Operative Day 0 1 2 3 4 5 6 7 Pre-Operative Transplant Dysglycemia Post-Operative Transplant Dysglycemia • Neuroendocrine response • History of insulin resistance • Inadequate pre-transplant management of hyperglycemia • Hyperglycemic medications, such as steroids and certain immunosuppressants • Para-phenomenon • Clinical inertia that fails to adjust or intensify insulin regiments • Knowledge gaps • Non-ADA diets. Table 1. Factors that influence dysglycemia peri-operatively. Our quality improvement project aims to adjust both pre-transplant management of hyperglycemia and correct post-transplant clinical inertia (bolded).