Diabetes Mellitus (DM)
ASSESSMENT
Data Gathering
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History
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Glucose testing & insulin dosing regimen
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Recent glucose readings
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History of hypoglycemic episodes - especially when NPO for procedures
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History of ketoacidosis
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Insulin dosing regimen
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Complications: neuropathy, nephropathy, & gastroparesis
Symptoms
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Hypoglycemic symptoms & awareness
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Early satiety & regurgitation of undigested food
Exam
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Sensory abnormalities
Risk Stratification
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Diagnostic Studies
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Basic metabolic panel within 6 months (more recently if any change in status)
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ECG if undergoing non-low risk surgery (author's institution's criterion)
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Glycohemoglobin (A1c) if would impact management
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Literature mixed on utility & no clear, evidence-based cut-off for elective surgery
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Many orthopedic surgery programs utilize cut-offs (ranging from 7.0-8.5) above which they will not perform elective surgery; some professional societies also recommend this (Dhatariya et al & Barker et al)
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May also be useful if would impact postoperative management (eg, determine if basal insulin will be required for a patient normally on oral hypoglycemics only)
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Fructosamine - alternative to glycohemoglobin:
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Useful for determining average glucose over past 2-3 weeks; also useful for assessing glucose control in patients with ESRD and chronic hemolytic anemia (A1c unreliable)​
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Some literature suggests it may be more predictive than A1c of adverse outcomes in orthopedic surgery (Shohat et al & Mendez et al)
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MANAGEMENT
Indications for Surgical Delay
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Ketoacidosis or hyperosmolar hyperglycemic nonketotic syndrome
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Elective surgery and A1c exceeding program/institutional cut-off
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Elective surgery and glucose >400 mg/dl (author's opinion: based upon increased likelihood for immediate complications of hyperglycemia as well as impaired wound healing)
Medication Management
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POSTOPERATIVE GLUCOSE TARGET: 80-180 mg/dl
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Non-insulin therapies: hold on morning of surgery
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PREOPERATIVE:
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Exception: sodium-glucose transport protein 2 (SGLT-2) inhibitors may require withholding fo​r 3 days due to risk of euglycemic ketoacidosis
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Exception: glucagon-like peptide-1 (GLP-1) agonists may require withholding for week before GI surgery if dosed weekly
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POSTOPERATIVE:
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Hold while hospitalized & provide insulin as needed to achieve glucose of 80-180 mg/dl​
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Use of basal (long-acting) + bolus correction & nutritional (short-acting) insulin preferred over sliding scale-only insulin
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Insulin​
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Long-acting (eg, detemir, glargine): provide 60-80% of usual dose while NPO; otherwise continue at usual dose​
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Exception: For Toujeo and Tresiba, above dose adjustment may need to be done ​3 days before surgery due to extended half-life
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Intermediate-acting (eg, NPH): provide 1/2 of usual dose while NPO; otherwise continue at usual dose
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Short-acting (eg, regular, aspart): do not provide nutritional (scheduled for mealtimes) dosing while NPO; provide correction dosing as needed for hyperglycemia while NPO; continue at usual dose when eating usual diet
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70/30 or 75/25 insulin: give 1/3 of usual dose or give 50% of the intermediate-acting fraction of the usual dose while NPO; when eating, continue usual dose
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Insulin pump:
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Use 60-80% of usual basal rate & no boluses while NPO
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If surgery >3 hours or concern for impaired peripheral absorption or patient's ability to self-manage in immediate postoperative setting, remove pump in preop holding area and provide continuous IV insulin infusion (requires preop discussion with patient's diabetes management provider
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Intraoperative Management
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Check glucose prior to surgery & if >300, consider continuous IV insulin infusion
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Check glucose at least every 2 hours (more frequently if glucose <91 or >180)
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Give dextrose-containing IV fluids if glucose <91
COUNSELING & COMMUNICATION
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Collaborate with patients' diabetes management providers, especially if they use insulin pumps
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Provide preoperative hypoglycemia treatment instructions for while the patient is NPO at home​