Diabetes and anaesthesia in the era of eras

23 Pages·2015·0.17 MB·English

by  Margaret Tenison

REFERENCES
: Endotext.org Diabetes Manager
: Perioperative Management of Diabetic Patients: New
Controversies. Aldam, Levy & Hall BJA 2014
:Society of Ambulatory Anesthesia (SAMBA) Consensus
Statement on Perioperative Blood Glucose
Management in Diabetic Patients Undergoing
Ambulatory Surgery
PRINCIPLES OF ERAS
: The patient presents for surgery in the best possible
condition
: The patient is maintained in the best possible condition
peri-operatively
: The patient then recovers faster from their surgery.
ERAS AND DIABETES PERI-OPERATIVELY
: The patient has well controlled diabetes – HbA1c is less than 8
: All complications of diabetes are considered thoughtfully and checked if necessary.
: Perioperatively the blood glucose is kept within a suitable range.
: Hypoglycaemia is bad.
: Hyperglycaemia is bad.
: Glycaemic variability is bad.
: Ketoacidosis is REALLY bad.
: Hyperosmolar states are REALLY bad.
THE SAMBA ARTICLE
: Take a focussed history – what is the usual BGL, what is the hypo point, is the
patient fairly self-sufficient or do they need guidance?
: How do we manage oral anti-diabetic medication?
: How do we manage insulin?
: Is there a blood glucose level at which we should cancel surgery?
: What is the optimal intra-operative BGL?
: How do we maintain optimal BGL?
: What is the optimal peri-operative glucose monitoring?
: How should we identify and treat hypoglycaemia?
: What discharge advice should we give?
THE BJA ARTICLE
: Utility of HbA1c
: Perioperative use of metformin
: Optimal dose of peri-operative long acting insulin.
: Ideal blood glucose range and measurement error.
UTILITY OF HBA1C
: Now being used : HbA1c over 8 has
diagnostically been associated
with quadrupled
: High values
mortality after
strongly
cardiac surgery.
associated with
poor outcomes
PERIOPERATIVE USE OF METFORMIN
: Traditionally stopped to avoid lactic acidosis.
: No risk of hypoglycaemia
: Continuation peri-operatively actually associated with better outcomes
: Avoid combining with prolonged fasting and contrast media.
: Peri-operative continuation now endorsed by Australian Prescriber
OPTIMAL DOSE OF PERIOPERATIVE LONG-
ACTING INSULIN

: Long-acting (basal) insulin should be continued.
: A dose modification may be required.
: Patients are eating less.
: Patients are exercising less.
: Stress hormones may elevate BGL.
: 80% of patients given 80% of the long-acting insulin had satisfactory BGLs.
IDEAL BLOOD GLUCOSE RANGE
: 6-10.
: May need to be higher if HbA1c high.
: Above the hypo point.
: Check your meter is working and accurate.