Editing Peri-op diabetes

== '''Elective peri-op management of diabetes:''' ==

* Simple things:
** First on list
** Don't drive themselves to hospital (hypoglycaemia)
** Clear apple juice if hypo pre-op
** Consider pre and post op admission
* Referral to endocrinology:
** All type 1 diabetics
** All patients on subcut pump
* T1DM:
** Do not withhold basal insulin
** BSL hourly
** Check ketones if BSL > 15
** Use insulin infusion with 5% dextrose at q18h
** Do not stop insulin infusion unless already given insulin 2 hours previously
* SGLT2 (flozins):
** Cease 3/7 pre-op and only restart when patient is eating and drinking normally
** Day cases - withhold on day of procedure only
* Aim 6.1-10 mmol/L
* '''T2DM Oral'''
** Continue orals and non-insulin injectables until morning of surgery, then withhold day of surgery
** Restart when eating, except metformin, which should be withhold until renal function back to normal
* '''T1DM/T2DM insulin-controlled'''
** Short procedures (2 hours) can continue subcut insulin
*** If breakfast is likely to be only delayed, not missed, then can continue usual basal regime.
*** Morning procedures causing missed meals, or afternoon procedures:
**** Withhold short-acting while fasting
**** Give half usual morning dose of long-acting
**** Insulin pumps can continue at their usual basal rate
**** Run slow IV dextrose while fasting
**** T1DM - can reduce previous night's dose of long-acting by 20%. Not necessary in T2DM.
** Longer/complex procedures
*** Should be on insulin infusion started with enough time to bring sugars under control

== '''Acute management of T2DM in emergency patients''' ==

* Avoid sliding scale alone - usually inadequate
* Ideally should have a basal-bolus regime which is frequently adjusted

== '''SGLT-2 inhibitors in emergency cases - euDKA''' ==

* Epidemiology
** The overall risk of this happening is doubled compared to placebo but still really low - about 0.5% of patients per year
* Risk factors
** Lean patients
** Low-carbohydrate diet
** Hypovolaemic
** Low reserve of insulin-secreting cells (long-term insulin use, T1DM)
** Sudden reduction in insulin dose
** Increased requirement for insulin (acutely unwell, surgery, alcohol abuse)
** Hidden diagnosis of latent autoimmune diabetes of adulthood (LADA)
* Pathophysiology
** Urinary glucose excretion is independent of circulating insulin level
** Inhibition of SGLT2 may lead to increased glucagon and consequently liver production of glucose and ketones
** There is also a linked renal cotransporter, normally responsible for excreting lactate and ketones, that may be inhibited by SGLT-2 inhibitors
** Euglycaemic (meaning BSL<13.9) DKA can occur during illness or when ongoing glucosuria masks stress-induced requirements for insulin. DKA might be present due to lack of/resistance to insulin, but the BSL is not elevated due to ongoing urinary losses.
** Often a hyper-chloraemic metabolic acidosis complicates recovery from DKA
* Prevention
** Withhold SGLT-2 inhibitors three days prior
** Prevent hypovolaemia
* Diagnosis
** Check serum ketones in any patient fasting or with nausea/vomiting/anorexia who has had SGLT-2 inhibitors within past 3 days
** My plan: BD BSL and ketone checks, and daily VBG, until either the patient is eating again, or it's been 3/7 since SGLT-2 inhibitor
* Management
** Stop the SGLT-2 inhibitor
** Generally, both insulin and glucose are required to correct the problem
*** First, ensure K+ > 3.3 and volume resuscitate with 0.9% normal saline
*** Start insulin infusion as per protocol (generally 0.1IU/kg bolus followed by continuous infusion, although can just start with continuous infusion; replace 0.9% saline with 5% Dextrose with BSL<11.1)
**** Some say just start directly on Dextrose 5% infusion
*** Give bicarbonate if pH < 6.9, which may require additional administration of calcium
*** Once acid-base balance is restored, switch to subcutaneous insulin in an intensive regimen, such as 0.5-0.8IU/kg short-acting with meals and a long-acting insulin at night
** Talk to endocrinology before reinstating the SGLT-2 inhibitor
** See 'DKA' page




<<Peri-Op Guidelines for Patients with Type1 and Type2 Diabetes.pdf>>

[[Category:Endocrinology]]
[[Category:Intern education]]