Perioperative management of type 1 diabetes mellitus

Clinical recommendations in the management of the patient with type 1 diabetes on insulin pump therapy in the perioperative period: a primer for the anaesthetist

Insulin pump therapy is increasingly common in patients with type 1 diabetes. Many of these patients will require surgery at some point in their lifetime. Few doctors will have experience of managing these patients, and little evidence exists to assist in the development of guidelines for patients with insulin pump therapy, undergoing surgery.It is clear that during emergency surgery insulin pump therapy is not appropriate and should be discontinued, but patients undergoing some elective surgery can and should continue insulin pump therapy, without any adverse effect on their blood sugar control, or on the outcome of their surgery. Individual hospitals need to formalize guidance on the management of patients receiving continuous subcutaneous insulin therapy, to allow patients the choice to continue their therapy during surgery. This expert opinion presents anaesthetists with a suggested clinical framework to help facilitate continued insulin pump therapy, during elective surgery and into the postoperative period.

Impact of diabetes mellitus on surgical outcomes in sports medicine

Diabetes mellitus (DM) affects a significant proportion of the patients evaluated and treated by orthopedic surgeons who specialize in sports medicine. Sports-medicine-related conditions associated with DM include tendinopathy, adhesive capsulitis of the shoulder, and articular cartilage disease. This article reviews the current literature adressing the effect of DM on surgical outcomes in sports medicine. In general, patients with DM undergo operations more frequently and experience inferior surgical outcomes compared with patients without DM. Diabetes mellitus is associated with increased rates of complications from sports medicine procedures, such as infection, delayed healing, and failure of the operation. However, additional research is needed to determine the full impact of DM on patient outcomes in sports medicine. Surgeons should be cognizant of special considerations in the population of patients with DM and aim to tailor the surgical management of this growing patient population.

Insulin pump therapy in the perioperative period: a review of care after implementation of institutional guidelines

BACKGROUND

An institutional policy was previously established for patients with diabetes on insulin pump therapy undergoing elective surgical procedures.

METHOD

Electronic medical records were reviewed to assess documentation of insulin pump status and glucose monitoring during preoperative, intraoperative, and postanesthesia care unit (PACU) phases of care.

RESULTS

Twenty patients with insulin pumps underwent 23 procedures from March 1 to December 31, 2011. Mean (standard deviation) age was 58 (13) years, mean diabetes duration was 28 (17) years, and mean duration of insulin pump therapy was 7 (6) years. Nearly all cases (86%) during the preoperative phase had the presence of the device documented--an improvement over the 64% noted in data collected before the policy. Intraoperatively, 13 cases (61%) had the presence of the pump documented, which was higher than the 28% before implementation of the policy. However, documentation of pump status was found in only 38% in the PACU and was actually less than the 60% documented previously. Over 90% of cases had glucose checked in the preoperative area and the PACU, and only 60% had it checked intraoperatively, which was nearly identical to the percentages seen before policy implementation. No adverse events occurred when insulin pump therapy was continued.

CONCLUSIONS

Although some processes still require improvement, preliminary data suggest that the policy for perioperative management of insulin pumps has provided useful structure for care of these cases. The data thus far indicate that insulin pump therapy can be continued safely during the perioperative period.

Guidelines for application of continuous subcutaneous insulin infusion (insulin pump) therapy in the perioperative period

Case reports indicate that diabetes patients receiving outpatient insulin pump therapy have been allowed to continue treatment during surgical procedures. Although allowed during surgery, there is actually little information in the medical literature on how to manage patients receiving insulin pump therapy during a planned surgical procedure. A multidisciplinary work group reviewed current information regarding the use of insulin pumps in the perioperative period. Although the work group identified safety issues specific to surgical scenarios, it believed that with the use of standardized guidelines and a checklist, continuation of insulin pump therapy during the perioperative period is feasible. A sample set of protocols have been developed and are summarized. A policy outlining clear procedures should be established at the institutional level to guide physicians and other staff if the devices are to be employed during the perioperative period. Additional clinical experience with the technology in surgical scenarios is needed, and consensus should be developed for insulin pump use in the perioperative phases of care.

Perioperative glycemic control: use of a hospital-wide protocol to safely improve hyperglycemia

Perioperative hyperglycemia impairs immunity and contributes to increased susceptibility to infection, higher incidence of multiorgan dysfunction, and greater mortality. Strict glycemic control is associated with lower infection rates, decreased length of stay (LOS), and faster recovery. A protocol that standardized preoperative education, testing, and treatment of elevated blood glucose (BG) safely improved perioperative glycemic control. Preoperative average BG improved from 191 to 155 mg/dL (P=.016); postoperative average BG decreased from 189 to 168 mg/dL (P=.094). The percentage of patients presenting with BG greater than 180 mg/dL preoperatively and achieving BG less than 180 mg/DL postoperatively increased from 21% to 43% (P = .09). Even though some results were statistically non-significant, the data showed a trend toward improvement with the new protocol. Good perioperative glycemic control, without an increased risk of hypoglycemia, is achievable.

Perioperative management of diabetes and hyperglycemia in patients undergoing orthopaedic surgery

Persons with diabetes undergo more surgical procedures, have a higher perioperative risk of complications, and have longer hospital stays than do persons who do not have diabetes. Persons with diabetes are frequently overweight, have a high prevalence of cardiovascular risk factors, and are more likely to suffer from chronic musculoskeletal conditions and traumatic injuries that require orthopaedic attention. Surgery frequently disrupts usual diabetes management, requiring adjustments to the treatment regimen. Suboptimal perioperative glucose control may contribute to increased morbidity, and it aggravates concomitant illnesses. Many patients undergoing elective or urgent orthopaedic surgery may have unrecognized diabetes or may develop stress-related hyperglycemia in the hospital. The challenge is to minimize the effects of metabolic derangements on surgical outcomes, reduce glycemic excursions, and prevent hypoglycemia. Recent guidelines advocate evidence-based glucose targets in the inpatient setting, and regimens for intravenous and subcutaneous insulin are gaining in popularity. Individualized treatment should be based on the ambient level of glycemic control, outpatient treatment regimen, presence of complications, nature of the surgical procedure, and type of anesthesia administered. Management by a multidisciplinary team and attention to discharge planning are key aspects of care during and after orthopaedic surgery.

New Insulin Analogues and Perioperative Care of Patients with Type 1 Diabetes

While insulin remains the mainstay of managing type 1 diabetes, much has changed over the last 15 years. These changes should help in managing patients with type 1 diabetes during the perioperative period. More flexible insulin therapy has three components: 1) basal, 2) prandial and 3) corrective. Many patients, particularly younger patients, are using genetically modified recombinant human insulin analogues. Two of these analogues, aspart and lispro insulin, are rapid-acting with faster onset and offset than subcutaneous regular insulin, allowing both prandial and corrective boluses. Other insulin analogues, particularly glargine and possibly detemir, have a flat profile of up to 24 hours, providing improved basal insulin delivery. Basal insulin can also be provided by a continuous subcutaneous infusion of rapid-acting insulin via a computerised pump that also provides boluses on demand. There is little evidence to help choose the best management of patients with type 1 diabetes during surgery. Some authors still recommend glucose-potassium-insulin infusions for all patients with type 1 diabetes. We challenge this approach, given the flexibility of the newer insulin analogues and delivery systems. We suggest that for many procedures, patients’ usual regimens can be maintained in the perioperative period, providing less disruption and, possibly, greater safety. Both hyperglycaemia and hypoglycaemia reflect poor management: we suggest a target glucose range of 5 to 10 mmol/l. The importance of frequently measuring blood glucose and appropriate responses cannot be overemphasised.

How to manage perioperative endocrine insufficiency

Patients with endocrinopathies frequently present to the operating room. Although many of these disorders are managed on a chronic basis, patients may have acute changes in the perioperative period that, if left unrecognized, can have a negative effect on perioperative morbidity and mortality. It is imperative that anesthesiologists understand the implications of the surgical stress response on hormonal flux. This article focuses on the 4 most commonly encountered endocrinopathies: diabetes mellitus, hyperthyroidism, hypothyroidism, and adrenal insufficiency. Specific challenges pertaining to patients with pheochromocytoma are also discussed.

Surgery in the patient with endocrine dysfunction

Patients with preoperative endocrinopathies represent a particular challenge not only to anesthesiologists but also to surgeons and perioperative clinicians. The "endocrine axis" is complex and has multiple feedback loops, some of which are endocrine and paracrine related, and others that are strongly influenced by the surgical stress response. Familiarity with several of the common endocrinopathies facilitates management in the perioperative period. This article focuses on 4 of the most common endocrinopathies: diabetes mellitus, hyperthyroidism, hypothyroidism, and adrenal insufficiency. Perioperative challenges in patients presenting with pheochromocytoma are also discussed.

Surgery in the patient with endocrine dysfunction

Patients with preoperative endocrinopathies represent a particular challenge not only to anesthesiologists but also to surgeons and perioperative clinicians. The "endocrine axis" is complex and has multiple feedback loops, some of which are endocrine and paracrine related, and others that are strongly influenced by the surgical stress response. Familiarity with several of the common endocrinopathies facilitates management in the perioperative period. This article focuses on 4 of the most common endocrinopathies: diabetes mellitus, hyperthyroidism, hypothyroidism, and adrenal insufficiency. Perioperative challenges in patients presenting with pheochromocytoma are also discussed.

Impact of Diabetes Mellitus and Metabolic Disorders

Metabolic and endocrine disorders are common in the perioperative surgical patient. During surgical stress and critical illness, each hormonal system reveals characteristic changes that can be of diagnostic and prognostic significance. A number of endocrinopathies,electrolyte problems, or metabolic derangements may either preexist or develop during the course of surgical treatment. Early correction and tight control of blood glucose levels was shown to improve outcome in critically ill surgical patients. However, many other pharmacological interventions to correct endocrine alterations in critical illness have proven unsuccessful, most likely because of the many overlapping actions between the endocrine and immune systems, and are not standard of care in surgical patients.

Perioperative management of pediatric surgical patients with diabetes mellitus

Pediatric patients with diabetes are managed with increasingly complex regimens. To optimally manage these patients during the perioperative period, pediatric anesthesiologists must carefully consider the pathophysiology of the disease, patient-specific methods of treatment, status of glycemic control, and the type of surgery proposed. Important pediatric issues, including body size, pubertal development, and ability to tolerate nil per os status, must be considered. To keep pace with the array of options for treating diabetes in children, the perioperative plan should be developed in consultation with a pediatric endocrinologist. We present an algorithm that was developed at Children's Hospital Boston for the management of pediatric patients with either type 1 or type 2 diabetes mellitus presenting for surgery and general anesthesia. This collaborative effort between the pediatric anesthesia and endocrine services represents one example of a standardized approach to these patients that should facilitate care and improve management. Differences from previously published recommendations are highlighted, as are expected changes caused by the continued evolution of pediatric diabetes care.

IMPLICATIONS

The evolution of diabetes care for children has made the management of perioperative blood glucose levels a greater challenge for pediatric anesthesiologists. A standardized algorithm for the perioperative management of pediatric patients with type 1 or type 2 diabetes mellitus os presented.

A Critical Appraisal of the Role of Insulin Analogues in the Management of Diabetes Mellitus

Insulin is one of the oldest and best studied treatments for diabetes mellitus. Despite many improvements in the management of diabetes, the nonphysiological time-action profiles of conventional insulins remain a significant obstacle. However, the advent of recombinant DNA technology made it possible to overcome these limitations in the time-action profiles of conventional insulins. Used as prandial (e.g. insulin lispro or insulin aspart) and basal (e.g. insulin glargine) insulin, the analogues simulate physiological insulin profiles more closely than the older conventional insulins. If rapid-acting insulin analogues are used in the hospital, healthcare providers will need a new mind-set. Any error in coordination between timing of rapid-acting insulin administration and meal ingestion may result in hypoglycaemia. However, guidelines regarding in-hospital use of insulin analogues are few. The safety profile of insulin analogues is still not completely established in long-term clinical studies. Several studies have shown conflicting results with respect to the tumourigenic potential of this new class of agents. The clinical implications of these findings are not clear. Although novel insulin analogues are promising 'designer drugs' in our armamentarium to overcome some of the limitations of conventional insulin therapy, cost may be a limiting factor for some patients.

Management of diabetes in childhood: are children small adults?

Diabetes in childhood is the most common chronic disease and generally fits the type 1 category, even though other forms of non-autoimmune diabetes are now emerging in this age. At variance with adults, children and adolescents undergo physiological process, which may frequently require adjustments of clinical management of diabetes. Moreover, the hormonal and psychological changes during puberty may be crucial in conditioning management. Furthermore, common illnesses frequently affecting children may also destabilise metabolic control. Consequently, education in children is the cornerstone of treatment. This review focuses on the several and peculiar aspects of practical management of diabetes in paediatric age, which require professional figures such as paediatricians, nurses, dieticians, psychologists, social assistants originally trained in paediatric area, able to deal with the age-related medical, educational, nutritional and behavioural issues of diabetes.

Assessment and therapy of selected endocrine disorders

Diabetes remains the most commonly encountered endocrinopathy with the incidence of type 2 doubling in the past decade. The prevalence of diabetes is projected to continue to increase dramatically over the next several decades unless major public health initiatives are successful in stemming this growth. Both type I and 2 diabetics more frequently require surgical and critical care than their non-diabetic counterparts. Type 1 and 2 diabetics also sustain greater peri-operative morbidity and mortality. Careful preoperative assessment and appropriate perioperative intervention may limit this. There is increasing evidence that maintenance of normal blood glucose in the perioperative period and during critical illness is beneficial for diabetic and non-diabetic patients. More data will hopefully be forthcoming to substantiate recent reports and identify the mechanisms of improved outcome. Thyroid disease remains a commonly encountered pathology that is more readily identified and controlled in the modern era of radioimmune assays of thyroid hormone and successful medical and surgical therapies. Severe hypothyroidism and thyroid storm are associated with significant increases in perioperative morbidity and mortality. Recognition of these entities or those at risk for developing them post operatively is crucial in initiating timely and effective therapy. Primary Al is uncommon, but results in glucocorticoid and mineralocorticoid deficiency. Tertiary Al is far more common, most often secondary to iatrogenic therapy with exogenous glucocorticoids for the management of chronic diseases such as connective tissue disorders, anti-rejection regimes, and severe asthma. Glucocorticoid replacement or supplementation is needed on a case-by-case basis and should be individualized based on chronic steroid dose, duration, and stress of the surgical procedure. Perioperative steroid dosing regimes now recommend lower doses for shorter periods than previously suggested. More recently Al has been recognized in two populations, elderly patients undergoing major surgery and a subgroup of patients with septic shock. Timely diagnosis using synthetic ACTH stimulation testing and stress glucocorticoid, and possibly mineralocorticoid therapy, seems to reverse these processes and improve recovery. Although uncommon, patients with pheochromocytoma who undergo open or laparoscopic resections remain diagnostic and therapeutic challenges. Perioperative outcome seems to have improved, in part, related to newer therapies and less invasive surgeries when indicated. The appropriate preoperative assessment and management of patients with various endocrinopathies is important to optimize outcome and limit avoidable complications. Hopefully additional evidence based guidelines will be forth-coming particularly in caring for the ever increasingly encountered perioperative diabetic.

Perioperative Management of Diabetes Mellitus

Diabetes mellitus (DM) is a common disease with serious microvascular and macrovascular complications. Individuals with DM have a higher rate of surgical procedures. A number of recent studies have demonstrated that poor perioperative glucose control is associated with adverse postoperative outcomes. There is growing evidence that interventions aimed at improving glycemic control in the perioperative period can improve short- and long-term outcomes in subjects with DM undergoing surgery. A variety of treatment options are now available for the management of DM. With judicious use of these regimens it should be possible to maintain good glycemic control in the perioperative period. A collaborative approach involving the surgical team, nursing professionals, primary care physicians, and specialists should be capable of successfully implementing effective regimens in the perioperative period.