Download Peri-operative management of the surgical patient with diabetes

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Peri-operative management of the
surgical patient with diabetes
GL059
Approval
Approval Group
Job Title, Chair of Committee
Anaesthetics Clinical Governance
Chair Anaesthetic governance
Date
Nov 2016
Change History
Version
Date
Author, job title
Reason
7
Apr 2016
J Rechner, A Pal
Update and
review
Consultant Anaesthetist, Endocrine
Consultant
7.1
Nov 2016
J Rechner, A Pal
Consultant Anaesthetist, Endocrine
Consultant
Author:
Job Title:
Policy Lead:
Location:
J Rechner, A Pal
Consultant Anaesthetist, Endocrine Consultant
Planned Care Group Director
Corporate governance shared drive – GL059
Date:
Review Date:
Version:
Review, no
changes
Nov 2016
Nov 2018
Version 7.1
Contents
1. Purpose
2. Introduction
3. Scope
4. Referring primary care physician
5. Surgical department
6. Pre-operative assessment
7. Management of existing therapy
8. Intra-operative care and monitoring
9. Fluid management
10. Variable rate intravenous insulin infusion
11. Returning to pre-operative medication and diet
12. Patients with diabetes requiring emergency surgery
1. Purpose
The purpose of this clinical guideline is to describe the peri-operative management of the surgical
patient with diabetes.
2. Introduction
The Joint British Diabetes Societies produced guidance in 2011 relating to the management of
adults with diabetes undergoing surgery and elective procedures. This was revised in September
2015 with considerably greater focus given to maintaining good glucose control in the perioperative period as there is now good data to show that poor glucose control peri-operatively is
associated with an increased risk of all the complication of surgery as well as an increased length
of hospital stay.
The Association of Anaesthetists of Great Britain and Ireland subsequently published guidance in
September 2015 which mirrors the JBDS guidance.
Diabetes affects 10-15% of the surgical population, and, as the number of people with diabetes
continues to rise (by up to 50% in the next decade), so too will the number of patients requiring
surgery with diabetes continue to rise. Perioperative mortality rates are up to 50% greater than in
the non-diabetic population with a two to three fold increase in complications such as respiratory
infections, surgical site infections, myocardial infarction and acute kidney injury.
In order to reduce perioperative complications it is important that diabetes be as well controlled
as possible before elective surgery, with a HbA1c of <69 mmol/mol for elective cases.
Author:
Job Title:
Policy Lead:
Location:
J Rechner, A Pal
Consultant Anaesthetist, Endocrine consultant
Planned Care Group Director
Corporate Governance shared drive – GL059
Date:
Review Date:
Version:
Nov 2016
Nov 2018
Version 7.1
2
3. Scope
This clinical guideline applies to all health professionals involved in the management of the
surgical patient with diabetes. This includes the referring primary care physician and health
professionals in the secondary care setting involved in perioperative management of surgical
patients.
4. Referring Primary Care Physician
Glycaemic control should be checked at the time of referral for surgery. Information about
duration, type of diabetes, current treatment and complications should be made available to the
secondary care team.
If the HbA1c is greater than 69mmol/mol, every effort should be made to improve control. For
frail elderly patients, or patients with multiple co-morbidities at risk of hypoglycaemia, a higher
upper limit of 75 mmol/mol may be appropriate.


For patients currently under a secondary care team, the referring primary care physician
should communicate directly with this team for advice.
For patients managed in the community, the referring primary care physician can
refer/communicate with: a community endocrinology consultant, community diabetic
specialist nurse or secondary care physician, if required.
This information should be included in the referral for surgery.
5. Surgical Department.
Referrals to surgical departments for elective surgery may not be accepted if the above criteria are
not met.
6. Pre-operative assessment
Patients with diabetes attending pre-operative assessment clinics should have their Hba1c
checked if not done so within the previous month.
Patients with diabetes should be provided with verbal and written information about diabetes in
the peri-operative period.
If the HbA1c is >69 mmol/mol, and a specialist opinion, as defined above, has not been sought,
elective surgery should be delayed while control is improved. Surgical procedures which are
Author:
Job Title:
Policy Lead:
Location:
J Rechner, A Pal
Consultant Anaesthetist, Endocrine consultant
Planned Care Group Director
Corporate Governance shared drive – GL059
Date:
Review Date:
Version:
Nov 2016
Nov 2018
Version 7.1
3
urgent (or involve additional risks if delayed) should not be postponed without further discussion
with the surgeon. For frail elderly patients, or patients with multiple comorbidities, at risk of
hypoglycaemia, a higher upper limit of 75 mmol/mol may be appropriate.
All patients with a HbA1c >69mmol/mol should receive written information advising them of the
increased risks of surgery and providing advice on improving diabetic control.
Patients who are being discharged back to their GP should receive written information asking
them to attend their GP. A referral to a diabetes specialist, as defined above, may be warranted.
The patient should be advised to attend their GP surgery at three months for a repeat HbA1c
(fructosamine is also acceptable). If the HbA1c at three months is less than 69mmol/mol
(fructosamine less 345 µmol ), the GP or patient can contact the operating surgeon and be listed
for surgery. If the HbA1c remains high, the GP should make an active decision with the patient that
all possible avenues for improvement have been explored and should communicate this, along
with any interventions/referrals, to the anaesthetic department. As different surgical procedures
carry different risks, the decision to proceed with poorly controlled diabetes will lie with the
surgeon and anaesthetist.
Patients undergoing procedures, for whom delaying surgery may incur other complications (such
as laparascopic cholecystectomies), with a HbA1c greater than 69mmol/mol, will require the
anaesthetist to communicate with the operating surgeon in order to agree an acceptable time
frame for optimisation. If time allows, an internal referral to the diabetes team is indicated. Please
fax a referral to CAT 9 on 7678.
Patients undergoing urgent surgery, with a HbA1c greater than 69mmol/mol, should be referred
internally to the diabetes team by fax to CAT 9 on 7678 or discussed with the on call diabetes
registrar on bleep 199/192. The patient may need to be admitted the night before for a variable
rate intravenous insulin infusion (VRIII) if on the morning list, or first thing in the morning if on an
afternoon list.
In a small number of cases, following discussion with a diabetes specialist, it may not be possible
to improve diabetic control. In these circumstances the patient should be made aware of the
increased risks. These patients may need to be admitted earlier than normal in case they require a
variable rate intravenous insulin infusion (VRIII).
Pre-operative tests to assess co-morbidities should be ordered in line with NICE guidance. Random
blood glucose is no longer indicated.
Patients should be first on the operating list to minimise the period of fasting.
Author:
Job Title:
Policy Lead:
Location:
J Rechner, A Pal
Consultant Anaesthetist, Endocrine consultant
Planned Care Group Director
Corporate Governance shared drive – GL059
Date:
Review Date:
Version:
Nov 2016
Nov 2018
Version 7.1
4
Patients should be provided with written instructions about management of their diabetes
medication on the day of surgery and management of hypo- or hyperglycaemia in the perioperative period.
Patients should be advised to carry a form of glucose in case of symptoms of hypoglycaemia; this
should be a clear fluid or suitable alternative.
7. Management of existing therapy
Patients should be allowed to retain control and possession of, and continue to self-administer,
their medication.
Patients on continuous subcutaneous insulin pumps (CSII) are very well educated and will be able
to self-manage their diabetes appropriately if given the opportunity to do so. If the starvation
period is short, pump therapy should be continued and patients should remain on their basal rate
until they are eating and drinking normally. If more than one meal is missed, the pump should be
removed and a VRIII used. Significant hyperkalaemia may occur after discontinuation of an insulin
pump. CBG and electrolytes should be checked and hypoglycaemia treated in the normal way.
Insulin-Short starvation time-no more than one missed meal
Author:
Job Title:
Policy Lead:
Location:
J Rechner, A Pal
Consultant Anaesthetist, Endocrine consultant
Planned Care Group Director
Corporate Governance shared drive – GL059
Date:
Review Date:
Version:
Nov 2016
Nov 2018
Version 7.1
5
Day
before
AM list
admission
Insulin
Once daily (Lantus,
Levemir, Tresiba,
Insulatard, Humulin I,
Insuman)
Twice daily
Biphasic or ultra-long
acting (Novomix 30,
Humulin M3, Humalog
Mix 25, Humalog Mix
50, Insuman Comb 25,
Insuman Comb 50,
Levemir, Lantus)
Short-acting (animal
neutral, novorapid,
Humulin S Apidra)
and
Intermediate-acting
(animal isophane,
insulatard, Humulin I,
Insuman)
Three to five injections
daily
Day of surgery
On VRIII
PM list
Reduce
dose by
20%
Reduce dose by 20%
Reduce dose by 20%
No dose
change
Halve the usual morning dose. Leave evening
dose unchanged
Stop until eating and
drinking
No dose
change
Calculate total morning dose of insulin; give half
as intermediate-acting only. Evening dose
unchanged
Stop until eating and
drinking
No dose
change
Basal bolus regime: Omit morning
and lunchtime short-acting
insulins; keep basal unchanged
Premixed AM insulin: Halve
morning dose and omit lunch
time dose
Give usual
morning
insulin.
Omit lunch
time dose
Stop until eating and
drinking
Oral hypoglycaemic agents-short starvation time-no more than one missed meal
Author:
Job Title:
Policy Lead:
Location:
J Rechner, A Pal
Consultant Anaesthetist, Endocrine consultant
Planned Care Group Director
Corporate Governance shared drive – GL059
Date:
Review Date:
Version:
Nov 2016
Nov 2018
Version 7.1
6
Agent
Day before
admission
Day of surgery
AM list
On VRIII
PM list
Drugs that require omission when fasting owing to risk of hypoglycaemia
Meglitinides
Take as normal
Omit AM dose
Give AM dose if
(repaglinide,
eating
nateglinide)
Sulphonylureas
Take as normal
Omit AM dose
(glibenclamide,
gliclazide, glipizide)
Drugs that require omission when fasting owing to risk of ketoacidosis
SGLT-2 inhibitors
Take as normal
Halve the morning dose; normal evening
(dapagliflozin,
dose
canagliflozin)
Drugs that may be continued when fasting
Acarbose
Take as normal
Take as normal
DPP-IV inhibitors
(sitagliptin,
vildagliptin,
saxagliptin,
alogliptin, linagliptin)
GLP-1 analogues
(exenatide,
liraglutide,
lixisenatide)
Pioglitazone
Take as normal
Take as normal
Take as normal
Take as normal
Take as normal
Take as normal
Stop until eating and
drinking
Stop until eating and
drinking
Stop until eating and
drinking
Stop until eating and
drinking
Stop until eating and
drinking
Take as normal
Stop until eating and
drinking
Metformin*
Take as normal
Take as normal
Stop until eating and
drinking
*Metformin. Omit on morning of procedure and for the following 48 hrs if contrast medium is to be used or the eGFR
2
is less than 60 ml/min.1.73/m
8. Intra-operative care and monitoring
The aim of intra-operative care is to maintain good glycaemic control and normal electrolyte
concentrations.
An intra-operative CBG range of 6–10 mmol/L should be aimed for (an upper limit of 12 mmol/L
may be tolerated at times).
The CBG should be checked before induction of anaesthesia and monitored regularly during the
Author:
Job Title:
Policy Lead:
Location:
J Rechner, A Pal
Consultant Anaesthetist, Endocrine consultant
Planned Care Group Director
Corporate Governance shared drive – GL059
Date:
Review Date:
Version:
Nov 2016
Nov 2018
Version 7.1
7
procedure (at least hourly, or more frequently if the results are outside the target range).
The CBG, insulin infusion rate and substrate infusion should be recorded on the anaesthetic
record.
Management of intra-operative hyperglycaemia and hypoglycaemia
If the CBG exceeds 12 mmol/L and insulin has been omitted, capillary blood ketone levels should
be measured. If the capillary blood ketones are > 3 mmol/L or there is significant ketonuria (> 2+
on urine sticks) the patient should be treated as having diabetic ketoacidosis (DKA). Diabetic
ketoacidosis is a medical emergency and specialist help should be obtained from the diabetes
team. Please contact the diabetes registrar on bleep 199/192.
If DKA is not present, the high blood glucose should be corrected using subcutaneous insulin or by
altering the rate of the VRIII (if in use). If two subcutaneous insulin doses do not work, a VRIII
should be started. Insulin doses should be written in full, avoiding abbreviations of the words
‘units’.
1) Treatment of hyperglycaemia in a patient with Type-1 diabetes
Subcutaneous rapid-acting insulin (such as Novorapid) should be given (up to a maximum of 6
units), assuming that 1 unit will drop the CBG by 3 mmol/L. If the patient is awake, it is important
to ensure that the patient is content with proposed dose (patients may react differently to
subcutaneous rapid-acting insulin). The CBG should be checked hourly and a second dose
considered only after 2 hrs.
2) Treatment of hyperglycaemia in a patient with Type-2 diabetes (including those on insulin)
Subcutaneous rapid-acting insulin (such as Novorapid) 0.1 unit/kgshould be given (up to a
maximum of 6 units). The CBG should be checked hourly and a second dose considered only after
2 h. A VRIII should be considered if the patient remains hyperglycaemic.
3) Treatment of intra-operative hypoglycaemia
For a CBG 4.0–6.0 mmol/L, 50 ml of glucose 20% (10 g) should be given intravenously; for
hypoglycaemia < 4.0 mmol/La dose of 100 ml of glucose 20% (20 g) should be given.
9. Fluid management
Author:
Job Title:
Policy Lead:
Location:
J Rechner, A Pal
Consultant Anaesthetist, Endocrine consultant
Planned Care Group Director
Corporate Governance shared drive – GL059
Date:
Review Date:
Version:
Nov 2016
Nov 2018
Version 7.1
8
It is now recognised that Plasmalyte solution is safe to administer to patients.
The initial fluid management for patients requiring a VRIII should be glucose 5% in saline 0.45%
pre-mixed with either potassium chloride 0.15% (20 mmol/L) or potassium chloride 0.3% (40
mmol/L), depending on the presence of hypokalaemia (< 3.5 mmol/L). Currently only the former is
available in 500ml bags in this Trust.
Fluid should be administered at the rate that is appropriate for the patient’s usual maintenance
requirements – usually 25–50 ml/kg/day (approximately 83 ml/h for a 70-kg patient).
Electrolytes should be checked daily in patients on a VRIII
10. Variable rate intravenous insulin infusion
A VRIII should be avoided if possible but is the preferred option in: patients who will miss more
than one meal; patients with Type 1 diabetes who have not received background insulin; patients
with poorly controlled diabetes and most patients with diabetes requiring emergency surgery.
Please refer to the Guideline for safe administration of the VRIII for adult in-patients with diabetes
(CG242). 50 units of Actrapid is mixed with 50ml 0.9% sodium chloride and administered
intravenously though an extension set with a Y connector for simultaneous administration of
glucose 5% in saline 0.45% with potassium chloride 0.15%. There should be an anti-syphon valve
on the insulin line and an anti-reflux valve on the dextrose saline line.
Rate of VRIII:
Blood glucose mmol/L
0 - 4
4.1 - 6.0
6.1 - 8.0
8.1 - 10.0
Over 10
Regimen A
Units/hr
Stop and treat hypo
1
2
3
4
Regimen B
Units/hr
Stop and treat hypo
1
3
4
6
If CBG remains above 10mmol/L for 4 hours move to regimen B. For patients already on insulin
treatment in excess of 100 units in 24hrs start on regimen B.
If CBG remains above 10mmol/L for 4 hours on regimen B please contact the Diabetes Specialist
team on bleep 199 or 192. Out of hours, it is reasonable for a suitably experienced doctor to either
increase the units of insulin per hour or decrease the rate of infusion of glucose 5% in saline 0.45%
with potassium chloride 0.15%. Unopposed intravenous infusion of insulin on the ward is not
recommended.
Author:
Job Title:
Policy Lead:
Location:
J Rechner, A Pal
Consultant Anaesthetist, Endocrine consultant
Planned Care Group Director
Corporate Governance shared drive – GL059
Date:
Review Date:
Version:
Nov 2016
Nov 2018
Version 7.1
9
11. Returning to pre-operative medication and diet
The postoperative blood glucose management plan, and any alterations to existing medications,
should be clearly communicated to ward staff.
If the patient has type-1 diabetes and a VRIII has been used, it must be continued for 30–60 min
after the patient has had their subcutaneous insulin. Premature discontinuation is associated with
iatrogenic DKA.
Oral hypoglycaemic agents should be recommenced at pre-operative doses once the patient is
ready to eat and drink; withholding or reduction in sulphonylureas may be required if the food
intake is likely to be reduced. Metformin should only be restarted if the estimated glomerular
filtration rate exceeds 50 ml/min.1.73 m2.
Restarting subcutaneous insulin for patients already established on insulin should commence once
the patient is able to eat and drink without nausea or vomiting. The pre-surgical regimen should
be restarted, but may require adjustment because the insulin requirement may change as a result
of postoperative stress, infection or altered food intake. The diabetes specialist team should be
consulted if the blood glucose levels are outside the acceptable range (6–12 mmol/L) or if a
change in diabetes management is required.
The transition from intravenous to subcutaneous insulin should take place when the next mealrelated subcutaneous insulin dose is due, for example with breakfast or lunch.
There should be an overlap between the end of the VRIII and the first injection of subcutaneous
insulin, which should be given with a meal and the intravenous insulin and fluids discontinued 3060 min later.
If the patient was previously on a long-acting insulin analogue such as Lantus, Levemir or Tresbia,
this should have been continued and thus the only action should be to restart his/her usual rapidacting insulin at the next meal as outlined above. If the basal insulin was stopped, the insulin
infusion should be continued until a background insulin has been given.
For the patient on a twice-daily, fixed-mix regimen, the insulin should be re-introduced before
breakfast or before the evening meal, and not at any other time. The VRIII should be maintained
for 30-60 min after the subcutaneous insulin has been given.
For the patient on a continuous subcutaneous insulin infusion, the subcutaneous insulin infusion
should be recommenced at the patient’s normal basal rate; the VRIII should be continued until the
Author:
Job Title:
Policy Lead:
Location:
J Rechner, A Pal
Consultant Anaesthetist, Endocrine consultant
Planned Care Group Director
Corporate Governance shared drive – GL059
Date:
Review Date:
Version:
Nov 2016
Nov 2018
Version 7.1
10
next meal bolus has been given. The subcutaneous insulin infusions should not be re-started at
bedtime.
12. Patients with diabetes requiring emergency surgery
A VRIII should be the default technique to manage a patient undergoing emergency surgery
because of the unpredictability of the starvation period.
Use of a fixed-rate intravenous insulin infusion. This should only be used if the patient requires
immediate surgery and has concurrent DKA. Early involvement of the diabetes inpatient specialist
team should be sought.
The aim is for the patient to be taken to the operating theatre with a CBG of 6–10 mmol/L (6–12
mmol/L may be acceptable), without overt DKA, and having been adequately resuscitated.
The CBG should be checked regularly (hourly as a minimum whilst acutely unwell),and a VRIII
established using dextrose 5% in saline 0.45% with pre-mixed potassium chloride as the
substrate.
The patient should be checked for ketonaemia (> 3.0 mmol.l1) or significant ketonuria (> 2+ on
urine sticks) if the CBG exceeds 12 mmol.l
If possible, long-acting insulin (Levemir, Lantus, Tresiba) should be continued in all patients at 80%
of the usual dose.
13. References
1. Association of Anaesthetists of Great Britain and Ireland Guideline: Peri-operative
management of the surgical patient with diabetes September 2015
2. JBDS Guideline: Management of adults with diabetes undergoing surgery and elective
procedures: Improving standards September 2015
3. Perioperative iv fluids in diabetic patients- don’t forget the salt- Simpson, Levy, Hall
Anaesthesia 2008, 1043-45
4. Day Surgery and the diabetic patient, - British Association of Day Surgery 2004
Author:
Job Title:
Policy Lead:
Location:
J Rechner, A Pal
Consultant Anaesthetist, Endocrine consultant
Planned Care Group Director
Corporate Governance shared drive – GL059
Date:
Review Date:
Version:
Nov 2016
Nov 2018
Version 7.1
11