Microsoft word - samba glycemic control consensus statement-summary-joshi.docx

Society for Ambulatory Anesthesia Consensus Statement on Perioperative Blood Glucose Management
in Diabetic Patients Undergoing Ambulatory Surgery
Girish P. Joshi, MB BS, MD, FFARCSI
Anesthesia & Analgesia 2010; 111: 1378-87
A systematic review of the literature was conducted according the protocol recommended by the Cochrane Collaboration. The consensus panel used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system for developing the consensus statement. It was revealed that the literature on perioperative glycemic control in patients undergoing ambulatory surgery is sparse and of limited quality. In absence of high quality evidence, recommendations were based on general principles of blood glucose control in diabetics, drug pharmacology, data from inpatient surgical population and clinical judgment. The consensus panel considered specific clinical questions. 1. Preoperative information specifically related to glycemic control should be obtained in the
diabetic patient?
• Level of glycemic control (as assessed by blood glucose levels and HbA1c, if available). • Type and dose of antidiabetic therapy (i.e., oral antidiabetics and/or insulin). • Frequency and manifestations of hypoglycemia. • Blood glucose level at which hypoglycemic symptoms occur. • Hospital admissions due to glycemic control issues. • Ability of the patient to reliably test their blood glucose levels. 2. How do we manage preoperative oral antidiabetic and non-insulin injectable therapy?
• Hypoglycemia does not occur in patients on oral antidiabetics except rarely with sulfonylureas, meglitinides, and non-insulin injectables. • It may not be necessary to discontinue these drugs prior to the day of surgery; however, they should not be taken on the day of surgery. • Lactic acidosis rarely occurs with metformin, thus, may not be necessary to discontinue it 48 h 3. How do we manage preoperative insulin therapy?
- Use "sick day" or "sleep" basal rates 75-100% of morning - Reduce nighttime dose if history morning dose of basal insulin may be administered on arrival to the ambulatory surgery facility - No change in the 50-75% of morning - See the comments for long- 50-75% of morning - Lispro-protamine only available - See the comments for long-acting insulins 4. Is there a preoperative blood glucose level above which one should postpone elective surgery?
• Surgery should be postponed in patients with hyperglycemic crisis such as ketoacidosis and • It may be acceptable to proceed with surgery in patients with preoperative hyperglycemia, if they had adequate long-term glycemic control. • In chronically poorly controlled diabetics, the decision to proceed with ambulatory surgery should be made in conjunction with the surgeon while taking into consideration the presence of other comorbidities and the potential risks of surgical complications. 5. What is the optimal intraoperative period blood glucose level?
• In patients with well-controlled diabetes, intraoperative blood glucose levels should be maintained less than 180 mg/dl (10 mmol/l). • However, chronically elevated blood glucose levels should be maintained at the level at which they 'live'. Also, do not acutely decrease the blood glucose levels. 6. How do we maintain optimal blood glucose levels?
• Subcutaneous administration of rapid-acting insulin analogs is the preferred method for achieving and maintaining target glucose levels. • There is not enough evidence to recommend a dosing schedule to optimize the blood glucose • The "rule of 1800 or 1500", which provides the expected decrease in blood glucose with each unit of insulin may be used. Thus, if the patients' daily insulin requirement were 60 units, one unit of insulin would reduce in blood glucose level by 25-30 mg (i.e., 1500/60 or 1800/60). 7. What are the other considerations specific to glycemic control in diabetic outpatients?
• Patients should travel with a suitable treatment for hypoglycemia that might occur in transit. • Aggressive nausea and vomiting prophylaxis is recommended. • Dexamethasone 4 mg can be used, but should be followed with appropriate monitoring of blood 8. What is the optimal perioperative blood glucose monitoring?
• Blood glucose levels should be checked on the patient's arrival to the facility as well as prior to • Intraoperative blood glucose monitoring can be performed every 1-2 hour, depending upon the duration of procedure and type of insulin used. For example, intraoperative monitoring may not be necessary for procedures less than 2 hours. • More frequent measurements may be required for patients who have received insulin and those 9. How should we identify and manage perioperative hypoglycemia?
• Blood glucose level of less than 70 mg/dl is generally considered as an alert value for • In the symptomatic patient, the preferred method for treatment of hypoglycemia is consumption of 15-20 gm of glucose, which is repeated until blood glucose rises and symptoms resolve. • Overzealous glucose administration should be avoided as hyperglycemia can have significant 10. What are the discharge considerations for diabetic outpatients?
• Patients should be observed in an ambulatory facility until the possibility of hypoglycemia from perioperatively-administered insulin is ruled out. 11. What advice should we give to patients for glucose control after discharge home?
• Patients should be instructed to check blood glucose levels frequently while fasting. • Patients should carry hypoglycemia treatments while traveling to and from the surgical facility. • Patients should be advised that transition to daily preoperative antidiabetic regimens should be delayed if normal caloric intake is delayed. Pharmacology of Oral Antidiabetic Agents
Glipizide (Glucotrol) Glyburide (DiaBeta, Micronase) Meglitinides: type-1, potentiates insulin secretion, decreases glucagon Non-insulin injectables
actions similar to glucagon-like peptide Suppresses appetite Delays gastric emptying secretion and hepatic glucose production Potentiates the effects of insulin Suppresses appetite Delays gastric emptying Pharmacology of Insulin.
Drug Class: Generic (Trade name)
Short-acting and Rapid-acting
Regular (Novolin R, Humulin R)
Intermediate-acting
NPH (Novolin N, Humulin N-NF)
Long-acting (peakless)
Glargine (Lantus)
Mixed Insulins (NPH + Regular)
70% NPH/30% Regular (Novolin 70/30,
Humulin 70/30) 50% NPH/50% Regular (Humulin 50/50) Mixed Insulins (Intermediate-acting + Rapid-acting analogs)
70% Aspart Protamine Suspension/30%
Aspart (Novolog Mix 70/30) 75% Lispro Protamine Suspension/25% Lispro (Humalog Mix 75/25) 50% Lispro Protamine Suspension/50% Lispro

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