Management of the hospitalized patient with type 1 diabetes mellitus

Peri-operative management of diabetes mellitus - A survey of current practices among Indian anesthesiologists

Background and Aims

Increased burden of diabetes in India has resulted in a spurt in the number of patients with diabetes posted for surgeries. The paucity of national guidelines can lead to marked practice variations in the peri-operative management of diabetes. This survey intends to discern current peri-operative practices among anesthesiologists working in medical colleges, tertiary care government, and private health care institutes of the country.

Material and Methods

An anonymous online survey comprising of 25 closed-ended questions was conducted using Google Forms® and disseminated through social media, emails, and messaging platforms. The questionnaire dealt primarily with the peri-operative management of diabetes in patients scheduled for elective surgery. The survey was conducted over a period of 1 month and targeted anesthesia resident trainees with more than 1-year experience, senior residents, and consultants working in India.

Results

Statistically significant difference was observed between the three types of health facilities with respect to prior evaluation for diabetes (P = 0.007), prioritizing operative list (P = 0.006), hospital encouragement of day care surgery (P < 0.001), glycated hemoglobin level (HbA1c) level >8.5 for postponement of surgery (P < 0.05), insulin infusion preference (P < 0.001), hourly intra-operatively capillary blood glucose (CBG) assessment (P = 0.021), and avoiding peri-operative use of Ringer's lactate (RL) (P = 0.025).

Conclusion

This survey primarily highlights the lack of prioritizing the operative list, early discontinuation of metformin, and reduced tendency to consider diabetics for day care surgeries.

Hyperglycemia in the Perioperative Period

Perioperative hyperglycemia is a risk factor in surgical patients. Complications, including infection and mortality, are associated with hyperglycemia in both diabetic and nondiabetic patients. Stress hyperglycemia results in a state of insulin resistance. Insulin administration has been shown to reduce the complications associated with hyperglycemia. Glycemic targets provide goals for individualized treatment of hyperglycemia in surgical patients in the preoperative, intraoperative, and postoperative periods.

Perioperative glycemic management in adults presenting for elective cardiac and non-cardiac surgery

Perioperative dysglycemia is associated with adverse outcomes in both cardiac and non-cardiac surgical patients. Hyperglycemia in the perioperative period is associated with an increased risk of postoperative infections, length of stay, and mortality. Hypoglycemia can induce neuronal damage, leading to significant cognitive deficits, as well as death. This review endeavors to summarize existing literature on perioperative dysglycemia and provides updates on pharmacotherapy and management of perioperative hyperglycemia and hypoglycemia in surgical patients.

A novel telemedicine protocol improved outcomes for high-risk patients with type 1 diabetes: A 3-month quality improvement project during the COVID-19 pandemic

Our endocrinology practice needed to protect its highest-risk patients with type 1 diabetes (T1D) during the COVID-19 pandemic. To do so, we needed to identify these patients and develop a protocol to keep them out of the hospital (to limit risk of infection and conserve medical resources), and do so without in-person visits. So we used our peer-reviewed software, Diabetes Reporting, to identify 87 patients whose glucose management indicator (GMI) scores were over 9%. The GMI is a method for estimating the laboratory A1C using the patient's actual blood glucose measurements over the past 90 days. A GMI (or A1C) over 9% indicates a heightened risk of diabetic ketoacidosis (DKA) and, possibly, a slightly higher risk of severe hypoglycemia (SH), the two most common acute complications leading patients with T1D to be hospitalized. We contacted these 87 at-risk patients and enrolled them in a quality improvement project. This project consisted of additional online meetings with their doctors as well as weekly reports generated by Diabetes Reporting for three months, between March 28, 2020 and June 28, 2020. We hypothesized that this heightened communication would reduce the incidence of DKA and SH among the participants by reducing their GMI. As a comparison group, we used data from the T1D Exchange, which showed that, among patients with an A1C over 9%, 6.7% were hospitalized for DKA and 7% experienced SH leading to loss of consciousness in a three-month period. This led us to predict 6 incidences of DKA and 6 incidences of SH among our 87 participants during the three-month period. Instead, we saw 2 incidences of DKA and 1 incidence of SH. Moreover, the mean GMI of our participants dropped from 9.91% to 9.25%, a clinically-significant 0.66% improvement, which supports the conclusion that our protocol helped avoid acute complications among a cohort of at-risk patients with T1D by improving glycemic control during a time when we were limited to largely online care. This telemedicine protocol merits further research for its potential to improve and lower costs of care for patients with T1D, particularly for those at higher risk for acute complications.

Management of Type 1 Diabetes in the Hospital Setting

PURPOSE OF REVIEW

The purpose of this article was to review recent guideline recommendations on glycemic target, glucose monitoring, and therapeutic strategies, while providing practical recommendations for the management of medical and surgical patients with type 1 diabetes (T1D) admitted to critical and non-critical care settings.

RECENT FINDINGS

Studies evaluating safety and efficacy of insulin pump therapy, continuous glucose monitoring, electronic glucose management systems, and closed loop systems for the inpatient management of hyperglycemia are described. Due to the increased prevalence and life expectancy of patients with type 1 diabetes, a growing number of these patients require hospitalization every year. Inpatient diabetes management is complex and is best provided by a multidisciplinary diabetes team. In the absence of such resource, providers and health care staff must become familiar with the features of this condition to avoid complications such as severe hyperglycemia, ketoacidosis, hypoglycemia, or glycemic variability. We reviewed most recent guidelines and relevant literature in the topic to provide practical recommendations for the inpatient management of patients with T1D.

Perioperative Hyperglycemia Management: An Update

An association between perioperative hyperglycemia and adverse outcomes has been established in surgical patients, 1 -3 with morbidity being reduced in those treated with insulin.5 -6 A practical treatment algorithm and literature summary is provided for surgical patients with diabetes and hyperglycemia.

The Emory University Perioperative Algorithm for the Management of Hyperglycemia and Diabetes in Non-cardiac Surgery Patients

Hyperglycemia is a frequent manifestation of critical and surgical illness, resulting from the acute metabolic and hormonal changes associated with the response to injury and stress (Umpierrez and Kitabchi, Curr Opin Endocrinol. 11:75-81, 2004; McCowen et al., Crit Care Clin. 17(1):107-24, 2001). The exact prevalence of hospital hyperglycemia is not known, but observational studies have reported a prevalence of hyperglycemia ranging from 32 to 60 % in community hospitals (Umpierrez et al., J Clin Endocrinol Metab. 87(3):978-82, 2002; Cook et al., J Hosp Med. 4(9):E7-14, 2009; Farrokhi et al., Best Pract Res Clin Endocrinol Metab. 25(5):813-24, 2011), and 80 % of patients after cardiac surgery (Schmeltz et al., Diabetes Care 30(4):823-8, 2007; van den Berghe et al., N Engl J Med. 345(19):1359-67, 2001). Retrospective and randomized controlled trials in surgical populations have reported that hyperglycemia and diabetes are associated with increased length of stay, hospital complications, resource utilization, and mortality (Frisch et al., Diabetes Care 33(8):1783-8, 2010; Kwon et al., Ann Surg. 257(1):8-14, 2013; Bower et al., Surgery 147(5):670-5, 2010; Noordzij et al., Eur J Endocrinol. 156(1):137-42, 2007; Mraovic et al., J Arthroplasty 25(1):64-70, 2010). Substantial evidence indicates that correction of hyperglycemia reduces complications in critically ill, as well as in general surgery patients (Umpierrez et al., J Clin Endocrinol Metab. 87(3):978-82, 2002; Clement et al., Diabetes Care 27(2):553-97, 2004; Pomposelli et al., JPEN J Parented Enteral Nutr. 22(2):77-81, 1998). This manuscript reviews the pathophysiology of stress hyperglycemia during anesthesia and the perioperative period. We provide a practical outline for the diagnosis and management of preoperative, intraoperative, and postoperative care of patients with diabetes and hyperglycemia.