Perioperative management of adult diabetic patients. Postoperative period

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Perioperative management of adult diabetic patients.

Postoperative period

Gaelle Cheisson, Sophie Jacqueminet, Emmanuel Cosson, Carole Ichai,

Anne-Marie Leguerrier, Bogdan Nicolescu-Catargi, Alexandre Ouattara, Igor

Tauveron, Paul Valensi, Dan Benhamou

To cite this version:

Gaelle Cheisson, Sophie Jacqueminet, Emmanuel Cosson, Carole Ichai, Anne-Marie Leguerrier,

et al..

Perioperative management of adult diabetic patients.

Postoperative period.

Anaes-thesia Critical Care & Pain Medicine, Elsevier Masson, 2018, 37 (Supplement 1), pp.S27-S30.

�10.1016/j.accpm.2018.02.023�. �hal-02621647�

Guidelines

Perioperative

management

of

adult

diabetic

patients.

Postoperative

period

Gae¨lle

Cheisson

,

Sophie

Jacqueminet

,

Emmanuel

Cosson

,

Carole

Ichai

,

Anne-Marie

Leguerrier

_,

_Bogdan

_{Nicolescu-Catargi}

_,

_Alexandre

_Ouattara

_,

Igor

Tauveron

,

Paul

Valensi

,

Dan

Benhamou

*

,

working

party

approved

by

the

French

Society

of

Anaesthesia

and

Intensive

Care

Medicine

(SFAR),

the

French

Society

for

the

study

of

Diabetes

(SFD)

a_{Serviced’anesthe´sie–re´animationchirurgicale,hoˆpitauxuniversitairesParis-Sud,AP–HP,78,rueduGe´ne´ral-Leclerc,94275LeKremlin-Biceˆtre,France} b

Institutdecardio-me´tabolismeetnutrition,hoˆpitaldelaPitie´-Salpeˆtrie`re,AP–HP,75013Paris,France

c

De´partementdudiabe`teetdesmaladiesme´taboliques,hoˆpitaldelaPitie´-Salpeˆtrie`re,75013Paris,France

d

De´partementd’endocrinologie-diabe´tologie-nutrition,hoˆpitalJean-Verdier,universite´ Paris13,SorbonneParisCite´,CRNH-IdF,CINFO,AP–HP,93140Bondy, France

e

SorbonneParisCite´,UMRU1153INSERM/U1125INRA/CNAM/universite´ Paris13,93000Bobigny,France

f_{Servicedere´animationPolyvalente,hoˆpitalPasteur2,CHUdeNice,30,voieRomaine,06001Nicecedex1,France} g_{IRCAN(INSERMU1081,CNRSUMR7284),UniversityHospitalofNice,06001Nice,France}

h

Servicedediabe´tologie-endocrinologie,CHUdeRennes,CHUHoˆpitalSud,16,boulevarddeBulgarie,35056Rennes,France

i

Serviced’endocrinologie–maladiesme´taboliques,hoˆpitalSaint-Andre´,CHUdeBordeaux,1,rueJean-Burguet,33000Bordeaux,France

j

DepartmentofAnaesthesiaandCriticalCareII,MagellanMedico-SurgicalCenter,CHUdeBordeaux,33000Bordeaux,France

k

INSERM,UMR1034,BiologyofCardiovascularDiseases,universite´ Bordeaux,33600Pessac,France

l

Serviceendocrinologiediabe´tologie,CHUdeClermont-Ferrand,58,rueMontalembert,63000Clermont-Ferrand,France

m_{UFRme´decine,universite´ Clermont-Auvergne,28,placeHenri-Dunant,63000Clermont-Ferrand,France}

n_{UMRCNRS6293,INSERMU1103,ge´ne´tiquereproductionetde´veloppement,universite´ Clermont-Auvergne,63170Aubie`re,France} o

Endocrinologie-diabe´tologie,CHUG.Montpied,BP69,63003Clermont-Ferrand,France

ARTICLE INFO Articlehistory:

Availableonline16March2018 Keywords: Diabetes Perioperative Basal-bolus Insulinpump Hypoglycaemia Hyperglycaemia ABSTRACT

Followonfromcontinuousintravenousadministrationofinsulinwithanelectronicsyringe(IVES)isan importantelementinthepostoperativemanagementofadiabeticpatient.Thebasal-bolusschemeisthe mostsuitabletakingintoaccountthenutritionalsupplyandvariableneedsforinsulin,reproducingthe physiologyofanormalpancreas:(i)slow(long-acting)insulin(=basal)whichshouldimmediatelytake overfromIVESinsulinsimulatingbasalsecretion;(ii)ultra-rapidinsulintosimulateprandialsecretion (=bolusforthemeal);and(iii)correctionofpossiblehyperglycaemiawithanadditionalultra-rapid insulinbolusdose.Anumberofschemesareproposedtohelpcalculatethedosagesforthechangefrom IVinsulintosubcutaneousinsulin andforthebasal-bolusscheme.Postoperativeresumptionofan insulinpumprequiresthepatienttobeautonomous.Ifthisisnotthecase,thenitismandatoryto establishabasal-bolusschemeimmediatelyafterstoppingIVinsulin.Monitoringofbloodsugarlevels shouldbecontinuedpostoperatively.Hypoglycaemiaandseverehyperglycaemiashouldbe investigat-ed.Facedwithhypoglycaemia<3.3mmol/L(0.6g/L),glucoseshouldbeadministeredimmediately. Faced with hyperglycaemia >16.5mmol/L (3g/L) in a T1D or T2D patient treated with insulin, investigations for ketosis should be undertaken systematically. In T2D patients, unequivocal hyperglycaemiashouldalso callto mindthepossibilityofdiabetichyperosmolarity(hyperosmolar coma).Finally,themodalitiesofrecommencingprevioustreatmentsaredescribedaccordingtothetype ofhyperglycaemia,renalfunctionanddiabeticcontrolpreoperativelyandduringhospitalisation.

C _{2018TheAuthors.PublishedbyElsevierMassonSASonbehalfofSocie´te´ franc¸aised’anesthe´sieetde}

re´animation(Sfar).ThisisanopenaccessarticleundertheCCBYlicense(http://creativecommons.org/ licenses/by/4.0/).

* Correspondingauthor.

E-mailaddress:dan.benhamou@aphp.fr(D.Benhamou).

https://doi.org/10.1016/j.accpm.2018.02.023

2352-5568/ C_{2018TheAuthors.PublishedbyElsevierMassonSASonbehalfofSocie´te´ franc¸aised’anesthe´sieetdere´animation(Sfar).Thisisanopenaccessarticleunderthe}

1. Changefromintravenousinsulinelectronicsyringe(IVES)to

subcutaneous(SC)insulin

Practical sheet P summarises the main elements from this

chapter.

Thebasal-bolusschemeisthemostsuitableinthepostoperative

period taking intoaccount the variable nutritional supplies and

insulinrequirements.Itmorefaithfullyreplicatesthephysiologyof

thenormalpancreas:(i)basalsecretionsimulatedbyslow

(long-acting)insulinwhichshouldimmediatelyfollowonfromIVinsulin;

and(ii)prandialsecretionsimulatedbyanultra-rapidinsulinwhose

dosesdependonthequantityofcarbohydratesingestedduringthe

meal.Thecomparisonofthisschemetointermittentinjectionsof

rapidinsulinsignificantlyimprovesglycaemiccontrolanddecreases

thepostoperativecomplications[1].

According todifferentstudies,the initialdoseofslowinsulin

variesbetween0.3 and 1.5IU/kg [2].Several modelshave been

proposedtoassurethetransitionfromIVESinsulintoSCinsulin.The

mostwidelyusedisthatofAvanzinietal.[3]:thechangeismade

whenbloodsugarlevelsarestableforatleast24handatresumption

offeeding.Overall,halfofthetotaldoseofIVinsulincorrespondsto

thedoseofslowinsulin,theotherhalftothedosesofanultra-rapid

analogue(Fig.1).Somegroupsrecommendgiving80%oftheIVES

doseasslowinsulinandaddingafirstdoseofultra-rapidinsulinat

thefirstmeal[4–6].ForLazaretal.,itisnecessarytowaituntilthe

speedofinfusionis<3U/hbeforestartingfollow-on;ahigherspeed

signifiesanover-riskofpostoperativecomplications[6].

IftheIVESperfusionisgivenoverashortperiodoftime(<24h)

inpatientsnotpreviouslytreatedwithinsulinandwhoseblood

sugarlevelsremainraisedpostoperatively,it isadvisedtostart

insulinatadoseof0.5–1IU/kgdependingon theweightofthe

patient(halfslowinsulin–halfultra-rapidanalogue)andtoonly

givehalfofthedoseofultra-rapidanalogueanticipatedifthemeal

islight[2].

Overall, the workinggroup has made the following

recom-mendations:(PracticalsheetP):

 maintaintheelectronicsyringeuntilstablebloodsugarlevels

areobtained1.80g/L(10mmol/L);

 stoptheprotocolforIVESinsulintherapyattheresumptionof

oralfeeding;

 stoptheinsulinifthehourlyoutputis0.5IU/h,leaving the

syringeinsituiftheoutputis5IU/hwhichindicatesmajor

insulinresistance;

 maketheinjectionofslowinsulinimmediatelyafterstopping

thesyringe,besttime=20:00hrs.Iffollow-onisstartedbefore

20:00hrs,adaptthedosetothetimeofstartingandthenmake

thesecondinjectionat20:00hrs(totaldose);

 make the injection of ultra-rapid analogueat thefirst meal,

adaptingittothequantityofcarbohydratesingested.

2. Specificcaseofapatientonapersonalinsulinpump

(practicalsheetH)

In the postoperative period, the personal pump will be

reconnectedassoonasthepatientcanmanageautonomously.If

thepatientisnotautonomous,itismandatorytoinitiatea

basal-bolusschemebyimmediateSCinjectionofinsulin(practicalsheets

HandQ).

3. Managementofhypoglycaemia(practicalsheetS)

Monitoring of blood sugar levels should be continued

postoperatively to detect hyperglycaemia. The management

strategy is identicalduring all of theperioperativeperiod. The

measurementofcapillarybloodsugarlevelsshouldbedonewhen

faced with any symptom suggestive of hypoglycaemia in a

hospitalised patient. Due to hypoglycaemia unawareness, it is

importanttoscaleupregularbloodsugarmonitoringunderinsulin

orinsulinsecretors.

Facedwithahypoglycaemiaof<3.3mmol/L(0.6g/L),glucose

shouldbeadministeredimmediatelyevenintheabsenceofclinical

signs of hypoglycaemia. Conversely, we recommend glucose

administration for blood sugar levels between 0.7 and 1g/L

(3.8–5.5mmol/L)ifthepatientreportssignsofhypoglycaemia.

The oral route should be preferred when the patient is

conscious according to Practical sheet S. In a subject who is

unconsciousorunabletoswallow,IVglucoseshouldbe

adminis-teredimmediately.Oralglucoseadministrationwillbecarriedout

whenthepatientregainsconsciousness.

4. Managementofhyperglycaemia(sheetT)

Severehyperglycaemia(notablyketoacidosisor

hyperosmola-rity) should be investigated by carrying out postoperative

monitoring ofblood sugar levels.Thestrategy formanagement

isidenticalduringthewholeperioperativeperiod(Fig.2).

Intheperioperativeperiod,itisnecessarytoprioritisebloodsugar

measurements (possibility of recent imbalance). In the case of

hyperglycaemia>16.5mmol/L(3g/L)inapatientwithT1Dandina

patientwithT2Dtreatedwithinsulin,thepresenceofketosisshould

beinvestigatedsystematically.Intheabsenceofketosis,theaddition

ofanultra-rapidanalogueofinsulinandgoodhydrationshouldbe

initiatedrapidly. Inthe presenceof ketosis,the initialstages of

ketoacidosisshouldbesuspected,adutyphysicianshouldbecalled

and theadministration of anultra-rapidanalogue ofinsulin should be

started(andthetransfertoanICUshouldbediscussed).

InT2Dpatients,hyperglycaemiashouldalsosuggestdiabetic

hyperosmolarity(alsocalledhyperosmolarcoma)whoseclinical

manifestations are extremely variable and deceptive (asthenia,

moderateconfusion,dehydration).Ifindoubt,bloodelectrolytes

shouldbemeasuredasamatterofurgency.Thiswillconfirmthe

hyperosmolarity (>320mosmol/L) and will lead to specific

managementinanICU.Exceptforalife-threateningemergency,

ketosisandhyperosmolarityshouldleadtothepostponementof

surgery.

5. Followonbeforedischarge

Thetherapeuticmodalitiesbeforedischargefromhospitalare

describedbelowandaredependentonseveralcriteria:(i)thetype

ofhyperglycaemia(stress,diagnosisofdiabetes,knowndiabetes);

(ii)theglycaemiccontrolinknowndiabeticsbeforetheprocedure

(HbA1c);(iii)thedosesofinsulinandglycaemiccontrol(basedon

capillaryblood sugarlevels)duringhospitalisation;and(iv)the

treatmentbeforehospitalisation(non-insulindrugsorinsulin).

The treatment and follow-up are adapted according to a

personalised HbA1ctarget,remembering thatfor mostdiabetic

patientsitisaround7%.

5.1. T1DandT2Dwithmultipleinjections(practicalsheetsG,K)

In T1D, resumption of previous treatment combining basal

(slow)insulinandbolus(ultra-rapidanalogue)insulinisessential.

Patientsleaveontheirusualinsulinschemebutatthedosesthey

took in hospital; subsequent consultations can be planned at

discharge:

 HbA1c <8%,consultation with thetreating physician at one

month;

G.Cheissonetal./AnaesthCritCarePainMed37(2018)S27–S30 S28

 HbA1cbetween8and9%,distantconsultationwitha diabetol-ogist;

 HbA1c >9% or if unstable blood sugar levels (>2g/L or

11mmol/L),theadviceof a diabetologist is requestedbefore

dischargeforpossiblehospitalisationinaspecialisedservice.

5.2. T2Dwithoralanti-diabetics(OADs)only(practicalsheetsJ,R)

 HbA1c8%,previoustreatmentisresumedatthesamedoses

after48h(ifclearanceis>30mL/minforallOADsand>60mL/

minformetformin).Ultra-rapidinsulinisstartedandthendoses

aredecreasedprogressivelyuntilitcanbestopped.Thetreating

physician is consulted within one to two weeks to discuss

increasesindosesofOADsifnecessary(dependingontheHbA1c

targetforthepatient);

 HbA1cbetween8and9%,theOADsareresumedatthesame

doses if there is no contraindication, ultra-rapid insulin is

stopped, and slow-acting insulin is left in place. The patient

leaveswithhis(her)usualOADsandaninjectionofslowinsulin,

typeglargine(Lantus1

).Aprotocolfortheadaptationofdosesis

transmittedtoanursewhowillmanagethepatientathome.The

treatingphysicianisconsultedinthefollowingmonth.Adistant

consultationwithadiabetologistisplanned;

 HbA1c>9%and/orglycaemiccontrolnotachieved(bloodsugar

levels>11mmol/L or2g/L),thebasal-bolusschemeis leftin

placeandtheadviceofadiabetologistisrequestedforpossible

hospitalisationinaspecialisedservice.

5.3. T2DwithOADsandinsulinbeforehospitaladmission(practical

sheetK)

InT2Dpatientstreatedwithinsulinpreoperatively,thesame

strategycanbeproposed:

 HbA1c<8%:theprevious treatment is resumedat thesame

dosesasduringhospitalisation.Aconsultationwiththetreating

physicianisadvisablewithinonetotwoweeks;

 HbA1cbetween 8and9%:theprevious treatmentisresumed

and a consultation with a diabetologist is requested for

intensificationoftherapy;

 HbA1c>$9%or glycaemiccontrol notachieved(blood sugar

levels>11mmol/Lor2g/L):thebasal-bolusschemeisleftin

Fig.1.PracticalsheetP–CalculationofthedosefortransitionfromIVESinsulin tosubcutaneous(SC)insulin.IVES:intravenousinsulinbyelectronicsyringe;SC: subcutaneous.

placeandtheadviceofadiabetologistisrequestedforpossible

hospitalisationinaspecialisedservice.

5.4. Stresshyperglycaemia

Stress hyperglycaemiais characterisedbyblood sugarlevels

that may be raised with HbA1c <6.5%. Insulin is stopped

progressively dependingon capillary blood sugar levels, which

normalisequickly.Notreatment isnecessaryon dischargefrom

hospitalbutmonitoringisessentialas60%ofthesepatientswill

becomediabetic within one year accordingto Greci et al. [7]:

fastingbloodsugarlevelswillbemeasuredatonemonthandthen

annuallyandsystematicallyinallsituationsofstress.Thetreating

physicianshouldbeinformed.

5.5. Diabeticpatientswithpreviouslyunknowndisease

Hygieno-dietaryrulesareinstitutedwiththehelpofadietician.

Theadviceofadiabetologist isrequestedforpossible

establish-ment of treatment with OADsand then consultation with the

treatingphysicianatonemonth.

Itisessentialtoprovideagoodbasiceducationtoensurethatthe

patienthasunderstoodthediagnosisofdiabetes,themeaningand

consequencesofbothhyperglycaemiaandhypoglycaemia

(espe-ciallyinthecaseoftreatmentwithinsulinand/orhypoglycaemic

sulphonamides/glinides), self monitoring of blood sugar levels,

bloodsugartargets,dietaryadviceandpossiblyinjectiontechniques

(inthecaseofinjectabletreatment)andadaptationofinsulindoses

[8].Educationofthepatientisimportantsinceseveralstudieshave

clearlyshownthat errors occurintaking antidiabeticdrugsand

manyside-effects,particularlyhypoglycaemiawhich,islinkedto

theabsenceofeffectiveeducationduringhospitalisation[9,10].In

addition,individually-adaptededucationregardingdiabetesduring

hospitalisation permits better glycaemic control [11,12], fewer

subsequenthospitalisations[11,12],decreasedriskofketoacidosis

[12]and reductionof the durationofhospital stay[13]. Finally,

specialisededucationregardingdiabetesinpatientshospitalisedfor

cardiacsurgerysignificantlyreducesthefrequencyanddurationof

severe hyperglycaemias aswell asthe frequency of nosocomial

infections[14].

Thiseducationmaybeprovidedbyamobilediabetologyteam,

whichexistsinsomehospitals.Inothercases,thepatientshouldbe

givenadietaryadvice,andshouldbeinformedaboutthestepsto

take incase of hypoglycaemiaif thepatientleaves hospital on

insulinand/orhypoglycaemicsulphonamides/glinides.

Disclosureofinterest

Theauthorsdeclarethattheyhavenocompetinginterest.

Themembersoftheworkingpartyhavereceivedsupportfrom

theFrench Society of Anaesthesiaand IntensiveCare Medicine

(SFAR)andtheFrenchSocietyfortheStudyofDiabetes(SFD)for

transportandaccommodationwhennecessary.Thetwonational

bodieshavealsoprovidedhonorariafortranslationofthetexts.

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G.Cheissonetal./AnaesthCritCarePainMed37(2018)S27–S30 S30