Diabetes for surgeons

Dr. Maria Wolfs Assistant Professor Endocrinology and Metabolism St. Michaels Hospital

Outline

Background and evidence Approach to the perioperative patient with DM

The

patient The treatment The surgery

Case discussions

DM in hospitalized patients

Approximately 1 in 4 patients admitted to the hospital has a known diagnosis of diabetes 30% of patients with diabetes require >2 hospitalizations in any given year High prevalence of diabetes elderly patients residents of long-term-care facilities
up

to one third of adults aged 6575 yr 40% of those older than 80 yr

Umpierrez, GE et al. JCEM 2012;97:16-38

Perioperative hyperglycemia

Case control studies

increased

risk for adverse outcomes in patients undergoing elective noncardiac surgery

BG values > 11.1 mmol/l associated with

prolonged
wound

hospital length of stay increased risk of postoperative complications

infections and cardiac arrhythmias

Umpierrez, GE et al. JCEM 2012;97:16-38

Perioperative hyperglycemia

postoperative infections
2.7

times higher in patients with glucose > 12.2 mmol/liter than in those with glucose levels below 12.2 mmol/liter

3184 noncardiac general surgery patients

perioperative

glucose value above 8.3 mmol/liter associated with increased length of stay, hospital complications, and postoperative mortality

Umpierrez, GE et al. JCEM 2012;97:16-38

Reduced risk of infection

Infection
RR 0.41 (0.21- 0.71)

Murad, MH et al. JCEM 2012;97:49

Glycemic targets in hospital

non-critically ill patients treated with insulin

premeal

glucose of < 7.8 mmol/L random BG of <10.0 mmol/liter

avoid hypoglycemia (<3.9 mmol/liter)

insulin

dose should be reduced if glucose levels are between 3.9 mmol/liter and 5.6 mmol/L

higher glucose ranges BG < 11.1 mmol/liter

terminally

ill patients patients with severe comorbidities

Umpierrez, GE et al. JCEM 2012;97:16-38

Glycemic targets in hospital

Provided that their medical conditions, dietary intake and glycemic control are acceptable, patients with diabetes should be maintained on their prehospitalization oral antihyperglycemic agents or insulin regimens [Grade D, Consensus]. Perioperative glycemic levels should be maintained between 5.0 and 11.0 mmol/L for most other surgical situations, with an appropriate protocol and trained staff to ensure the safe and effective implementation of this therapy and minimize the likelihood of hypoglycemia [Grade D, Consensus].

CDA 2008 Clinical Practice Guidelines

Outline

Background and evidence Approach to the perioperative patient with DM

The

patient The treatment The surgery

Case discussions

Case #1

52F scheduled for TAH tomorrow am Type 2 DM x 6 years, obesity Medications

Metformin

1000mg bid Gliclazide MR 60mg am Humulin N 20u hs Atorvastatin 10mg hs Perindopril 8mg

Case #2

29M MVC multiple fractures and head injury Type 1 DM since age 4 Medications
Humalog

7-5-7 Lantus 12 units hs

On call to OR

Case #3

75M POD2 bowel obstruction Type 2 DM x 10 years A1c 7.6% Medications at home
Metformin

1000mg bid Gliclazide MR 120mg Sitagliptin 100mg

Case #4

58F scheduled for total thyroidectomy for multinodular goitre Type 2 DM for 10 years A1c 7.3% Metformin 1g bid Humulin Mix 25 60-0-40-0

Case #5

78M POD 5 hip fracture ORIF Type 2 diabetes Metformin 1000mg BID Glyburide 10mg BID Continuous NG feeds - swallowing concerns BS on oral meds 14-18 mmol/L

Approach to perioperative DM

The Patient The Treatment The Surgery

The Patient

Type 1 or Type 2
Type

1 need insulin at all times!!! Glycemic control A1c, SMBG

Diet
NPO,

DAT, clear fluids, NG feeds, TPN

Activity level Medications

Steroids

Organ dysfunction/failure Ischemia

The Treatment

Oral agents Insulin Both

9 Basal coverage 9 Correction factor

Oral anti-hyperglycemic drugs

Class
Biguanides

Agents
Metformin

Concern
Lactic acidosis

Stop if:
CHF, renal insufficiency (eGFR <30ml/min), hypoperfusion, or chronic pulmonary disease, at risk of developing renal failure and lactic acidosis, iv contrast dye NPO, reduce dose if diet reduced

Sulfonylurea

Gliclazide (Diamicron) Glyburide (Diabeta) Glimeperide (Amaryl)

Hypoglycemia (Elderly, impaired renal function, poor nutritional intake) Hypoglycemia

Repaglinide (Gluconorm) Nataglinide (Starlix)

NPO

Oral anti-hyperglycemic drugs

Class
DPPIV Inhibitors

Agents
Sitagliptin (Januvia) Saxagliptin (Onglyza) Linagliptin (Trajenta ) Pioglitazone (Actos) Rosiglitazone (Avandia)

Concern
Renal impairment: Sita eGFR <50 Saxa 2.5mg if eGRF 15-30 Lina approved in ESRD Causes CHF Rosi increased CV mortality Bladder CA Atypical fractures GI upset

Stop if:
NPO

Thiazolidined iones (TZD)

CHF CAD Liver failure NPO

Alphaglucosidase inhibitor

Acarbose

Insulin 101

BOLUS 60%

TDD = total daily dose of insulin BASAL insulin = 40% of TDD BOLUS insulin = 60% TDD

BASAL 40%

Insulin 101

TDD = total daily dose of insulin BASAL insulin = 40% of TDD BOLUS insulin = 60% TDD

Insulin 101

TDD = total daily dose of insulin BASAL insulin = 40% of TDD BOLUS insulin = 60% TDD

9 Basal coverage 9 Correction factor

Insulin 101
BOLUS 60%

BASAL 40%

Insulin pharmacokinetics
Humulin BOLUS BASAL Humalog Regular N Humalog Mix 25 Humulin 30/70 PUMP Novolin Novorapid Toronto NPH Levemir Novomix 30 Novolin 30/70 Sanofi Apidra Lantus Onset (h) 0.25-0.5 0.5 2 2 2 Peak (h) 1-2 2-3 6-8 Duration (h) 3 4-6 12-20 16-20 20-24

MIXED

9 Basal coverage 9 Correction factor

Insulin pharmacokinetics
Humulin BOLUS BASAL Humalog Regular N Humalog Mix 25 Humulin 30/70 PUMP Novolin Novorapid Toronto NPH Levemir Novomix 30 Novolin 30/70 Sanofi Apidra Lantus Onset (h) 0.25-0.5 0.5 2 2 2 Peak (h) 1-2 2-3 6-8 Duration (h) 3 4-6 12-20 16-20 20-24

MIXED

Ensuring basal coverage

Day surgery with anticipated eating soon

Basal coverage for AM of surgery Hold until eating Usual dose of bedtime N Usual dose of bedtime Lantus or Levemir 20% of TDD as morning N Usual dose of bedtime N 70% of am N Continue usual dose of Lantus or Levemir Continue basal rate

Usual DM regimen Oral agents only Oral agents + bedtime N Oral agents + bedtime Lantus or Levemir Mixed insulin BID MDI with bedtime N MDI with am and bedtime N MDI with Lantus or Levemir Insulin pump

Basal insulin
Humulin BASAL N Novolin NPH Levemir Sanofi Lantus Onset (h) 2 2 2 Peak (h) 6-8 Duration (h) 12-20 16-20 20-24

Subcutaneous N/NPH
40%

AM 60% HS 25% q6h 33% q8h

Levemir/Lantus

100% HS

Intravenous drip

Basal insulin = 40% TDD

Home regimen Oral agents only Oral agents + bedtime insulin Mixed insulin BID MDI TDD Assume 30 units/day Assume 50 units/day Calculate daily dose e.g. 40-0-20-0 = ___ units/day Calculate daily dose e.g. Humalog 20-20-20-0 + Humulin N 16-0-0-24 = ___ units/day Estimate based on weight (kg) Type 1 kg x 0.3 units/kg/day Type 2 kg x 0.5 units/kg/day e.g. 60 kg woman Type 1 ___ units/day e.g. 100 kg man Type 2 ___ units/day Basal (40% TDD)

Unknown starting dose

Basal insulin = 40% TDD

Home regimen Oral agents only Oral agents + bedtime insulin Mixed insulin BID MDI TDD Assume 30 units/day Assume 50 units/day Calculate daily dose e.g. 40-0-20-0 = 60 units/day Calculate daily dose e.g. Humalog 20-20-20-0 + Humulin N 16-0-0-24 = 100 units/day Estimate based on weight (kg) Type 1 kg x 0.3 units/kg/day Type 2 kg x 0.5 units/kg/day e.g. 60 kg woman Type 1 18 units/day e.g. 100 kg man Type 2 50 units/day Basal (40% TDD) 12 20 24 40

Unknown starting dose

7 40

IV insulin infusion
Check for institutions pre-printed order set 1. Order insulin concentration

50 units of Humulin R in 500cc D5W 1 unit = 10 cc

IV insulin infusion
Check for institutions pre-printed order set 1. Order insulin concentration

2.

50 units of Humulin R in 500cc D5W 1 unit = 10 cc Glucose containing (D5W, :)

Order IV fluids

IV insulin infusion
Check for institutions pre-printed order set 1. Order insulin concentration

2.

50 units of Humulin R in 500cc D5W 1 unit = 10 cc Glucose containing (D5W, :)

Order IV fluids

3.

Calculate basal rate

Insulin 101 basal insulin

IV insulin drip rate = daily basal/24 hours

TDD Assume 30 units/day Assume 50 units/day Calculate daily dose e.g. 40-0-20-0 = 60 units/day Calculate daily dose e.g. Humalog 20-20-20-0 + Humulin N 16-0-0-24 = 100 units/day Estimate based on weight (kg) Type 1 kg x 0.3 units/kg/day Type 2 kg x 0.5 units/kg/day e.g. 60 kg woman Type 1 18 units/day e.g. 100 kg man Type 2 50 units/day 20 0.8 units/hour Basal IV insulin drip

Home regimen Oral agents only Oral agents + bedtime insulin Mixed insulin BID MDI

24

1.0 units/hour

40

1.5 units/hour

Unknown starting dose

7.2 20

0. units/hour 0.8 units/hour

Start infusion at 1 unit/hr = 10 cc/hr Capillary blood glucose check q1h

Basal rate May not be feasible in all settings

C Yu Jan 2012

IV insulin infusion
Check for institutions pre-printed order set 1. Order insulin concentration

2.

50 units of Humulin R in 500cc D5W 1 unit = 10 cc Glucose containing (D5W, :)

Order IV fluids

3. 4.

Calculate basal rate Calculate correction factor

IV insulin infusion
Check for institutions pre-printed order set 1. Order insulin concentration

2.

50 units of Humulin R in 500cc D5W 1 unit = 10 cc Glucose containing (D5W, :)

Order IV fluids

3. 4.

Calculate basal rate Calculate correction factor

9 Basal coverage 9 Correction factor

Correction factor

1 unit of insulin will lower BG by ___ mmol/L = 100/TDD

e.g.

70M home insulin regimen Humulin 30/70 30-0-20-0 TDD = ___ units

Correction factor

1 unit of insulin will lower BG by ___ mmol/L = 100/TDD

e.g.

70M home insulin regimen Humulin 30/70 30-0-20-0 TDD = 50 units CF = 100/TDD = 100/50 =___

Correction factor

1 unit of insulin will lower BG by ___ mmol/L = 100/TDD

e.g.

70M home insulin regimen Humulin 30/70 30-0-20-0 TDD = 50 units CF = 100/TDD = 100/50 = 2 1 unit of insulin will lower BG by 2 mmol/L

Correction factor

1 unit of insulin will lower BG by ___ mmol/L = 100/TDD

e.g.

60 F home insulin regimen Humulin 30/70 Humalog 6-5-8-0 + Glargine 14 hs TDD = ___ units CF = 100/TDD = 100/___ = ___ 1 unit of insulin will lower BG by ___ mmol/L

Correction factor

1 unit of insulin will lower BG by ___ mmol/L = 100/TDD

e.g.

60 F home insulin regimen Humulin 30/70 Humalog 6-5-8-0 + Glargine 14 hs TDD = 33 units CF = 100/TDD = 100/33 = 3 1 unit of insulin will lower BG by 3 mmol/L

Correction factor (100/TDD)

Target a BG of 6 mmol/L Start at 6+CF e.g. if TDD = 50 then CF = ___

Correction factor (100/TDD)

Target a BG of 6 mmol/L Start at 6+CF e.g. if TDD = 50 then CF = 2 then 6+2= ___

Correction factor (100/TDD)

Target a BG of 6 mmol/L Start at 6+CF e.g. if TDD = 50 then CF = 2 then 6+2=8

Rapid insulin correction (units) None 1 2 3 4 5 6 7 and call MD

Blood glucose (mmol/L) 4.0-8.0 8.1-10.0 10.1-12.0 12.1-14.0 14.1-16.0 16.1-18.0 18.1-20.0 > 20.1

Correction factor (100/TDD)

Target a BG of 6 mmol/L Start at 6+CF e.g. if TDD = 33 then CF = ___ then 6+__=__

Correction factor (100/TDD)

Target a BG of 6 mmol/L Start at 6+CF e.g. if TDD = 33 then CF = 3 then 6+3=9

Rapid insulin correction (units) None 1 2 3 4 5 and call MD

Blood glucose (mmol/L) 4.0-9.0 9.1-12.0 12.1-15.0 15.1-18.0 18.1-21.0 > 21.0

Start infusion at 1 unit/hr = 10 cc/hr Capillary blood glucose check q1h

If BG: <4.0 4.0-8.0 8.1-10.0 10.1-12.0 12.1-14.0 14.1-16.0 >16.0

Basal rate May not be feasible in all settings

Give additional bolus of: Give amp D5W, check BG in 15 min, call MD Continue at current rate 1 unit = 10 cc and continue at current rate 2 unit = 20 cc and continue at current rate Correction factor 3 unit = 30 cc and continue at current rate 4 unit = 40 cc and continue at current rate 5 unit = 50 cc, call MD

If additional bolus required for 2 consecutive hours, increase infusion rate by 0.5 u/hr = 5 cc/hr May need to adjust If no additional bolus required for 2 consecutive hours, decrease capillary blood glucose check to q4h
C Yu Jan 2012

The Surgery

Procedure Timing Plan to eat

The Surgery

Procedure
Procedure Major cardiovascular Likely post-op ICU Day surgery OR <2 hours DM regimen IV insulin drip IV insulin drip Ensure basal coverage until eating Ensure basal coverage until eating

Timing Plan to eat

The Surgery

Procedure Timing
Timing Morning case Afternoon Unknown Ensure adequate basal Adequate basal or IV insulin drip DM regimen

Plan to eat

The Surgery

Procedure Timing Plan to eat

Plan to eat Same day POD1 POD2 or later DM regimen Resume pre-op regimen once eating Ensure adequate basal Adequate basal or IV insulin drip

Outline

Background and evidence Approach to the perioperative patient with DM

The

patient The treatment The surgery

Case discussions

Case #1

52F scheduled for TAH tomorrow am DM2 x 6 years, obesity Medications

Metformin

1000mg bid Gliclazide MR 60mg am Humulin N 20u hs Atorvastatin 10mg hs Perindopril 8mg

The Patient

Type 1 or Type 2
Type

Type 2 A1c 7.8%

1 need insulin at all times!!! Glycemic control A1c, SMBG

Diet
NPO,

DAT, clear fluids, NG feeds, TPN

Activity level Medications

Steroids

Organ dysfunction/failure Ischemia

The Treatment

Oral agents Insulin Both Metformin

Gliclazide Humulin N

Oral anti-hyperglycemic drugs

Class
Biguinides

Agents
Metformin

Concern

Stop if:
CHF, renal insufficiency (eGFR <30ml/min), hypoperfusion, or chronic pulmonary disease, at risk of developing renal failure and lactic acidosis, iv contrast dye NPO, reduce dose if diet reduced

Lactic acidosis

Sulfonylurea

Gliclazide (Diamicron) Glyburide (Diabeta) Glimeperide (Amaryl)

Hypoglycemia (Elderly, impaired renal function, poor nutritional intake Hypoglycemia

Repaglinide (Gluconorm) Nataglinide (Starlix)

NPO

The Surgery

Procedure Timing Plan to eat

Write orders

Basal coverage Correction factor

Ensuring basal coverage

Usual DM regimen Oral agents only Oral agents + bedtime N Oral agents + bedtime Lantus or Levemir Mixed insulin BID MDI with bedtime N MDI with am and bedtime N MDI with Lantus or Levemir Insulin pump Basal coverage for AM of surgery Hold until eating Usual dose of bedtime N Usual dose of bedtime Lantus or Levemir 20% of TDD as morning N Usual dose of bedtime N 70% of am N Continue usual dose Continue basal rate

Correction factor (100/TDD)

Target a BG of 6 mmol/L Start at 6+CF e.g. if TDD = 50 then CF = 2 then 6+2=8

Rapid insulin correction (units) None 1 2 3 4 5 6 7 and call MD

Blood glucose (mmol/L) 4.0-8.0 8.1-10.0 10.1-12.0 12.1-14.0 14.1-16.0 16.1-18.0 18.1-20.0 > 20.1

Case #2

29M MVC multiple fractures and head injury Type 1 DM since age 4 Medications
Humalog

7-5-7 Lantus 12 units hs

On call to OR

The Patient

Type 1 or Type 2
Type

Type 1 A1c 8.5%

1 need insulin at all times!!! Glycemic control A1c, SMBG

Diet
NPO,

DAT, clear fluids, NG feeds, TPN

Sedentary post #

Activity level Medications

Steroids

Organ dysfunction/failure Ischemia

The Treatment

Oral agents Humalog 7-5-7-0 Insulin Lantus 12 hs Both

The Surgery

Procedure Timing Plan to eat

Write orders

Basal coverage Correction factor

Ensuring basal coverage

Usual DM regimen Oral agents only Oral agents + bedtime N Oral agents + bedtime Lantus or Levemir Mixed insulin BID MDI with bedtime N MDI with am and bedtime N MDI with Lantus or Levemir Insulin pump Basal coverage for AM of surgery Hold until eating Usual dose of bedtime N Usual dose of bedtime Lantus or Levemir 20% of TDD as morning N Usual dose of bedtime N 70% of am N Continue usual dose of Lantus or Levemir Continue basal rate

Continue Lantus 12 units hs

Basal insulin = 40% TDD

Home regimen MDI TDD Calculate daily dose e.g. Humalog 7-5-7-0 + Lantus 0-0-0-12 = 31 units/day Basal (40% TDD) 31 x 0.40 = 12

Either calculate basal from TDD or use Lantus dose = 12 units/day Insulin drip rate = basal rate/24 hours
12

units/24 hours = 0.5 units/hour

Correction factor (100/TDD)

Target a BG of 6 mmol/L Start at 6+CF e.g. if TDD = 33 then CF = 3 then 6+3=9

Rapid insulin correction (units) None 1 2 3 4 5 and call MD

Blood glucose (mmol/L) 4.0-9.0 9.1-12.0 12.1-15.0 15.1-18.0 18.1-21.0 > 21.0

Case #3

75M POD2 bowel resection Type 2 DM x 10 years Medications at home

Metformin

1000mg bid Gliclazide MR 120mg Sitagliptin 100mg

Case #3

75M POD2 bowel obstruction Type 2 DM x 10 years A1c 7.6% Medications at home
Metformin

1000mg bid Gliclazide MR 120mg Sitagliptin 100mg

Poor appetite post-op only minimal clear fluids Blood sugars 13-18 mmol/L Baseline eGFR >60ml/min Cr 95 Postop Cr 150

Case #3

Restart metformin + sitagliptin Restart metformin + gliclazide + sitagliptin Start sliding scale Start IV insulin drip Start basal insulin Start basal insulin + correction factor

Oral anti-hyperglycemic drugs

Class
Biguinides

Agents
Metformin

Concern
Lactic acidosis

Stop if:
CHF, renal insufficiency (eGFR <30ml/min), hypoperfusion, or chronic pulmonary disease, at risk of developing renal failure and lactic acidosis, iv contrast dye NPO, reduce dose if diet reduced

Sulfonylurea

Gliclazide (Diamicron) Glyburide (Diabeta) Glimeperide (Amaryl)

Hypoglycemia (Elderly, impaired renal function, poor nutritional intake Hypoglycemia

Repaglinide (Gluconorm) Nataglinide (Starlix)

NPO

Oral anti-hyperglycemic drugs

Class
DPPIV Inhibitors

Agents
Sitagliptin (Januvia) Saxagliptin (Onglyza) Linagliptin (Trajenta ) Pioglitazone (Actos) Rosiglitazone (Avandia)

Concern
Renal impairment: Sita eGFR <50 Saxa 2.5mg if eGRF 15-30 Lina approved in ESRD

Stop if:

NPO

Thiazolidine diones (TZD)

Causes CHF Rosi increased CV mortality Bladder CA Atypical fractures GI upset

CHF CAD Liver failure NPO

Alphaglucosidase inhibitor

Acarbose

Basal insulin = 40% TDD

Home regimen Oral agents only Oral agents + bedtime insulin Mixed insulin BID MDI TDD Assume 30 units/day Assume 50 units/day Calculate daily dose e.g. 40-0-20-0 = ___ units/day Calculate daily dose e.g. Humalog 20-20-20-0 + Humulin N 16-0-0-24 = ___ units/day Estimate based on weight (kg) Type 1 kg x 0.3 units/kg/day Type 2 kg x 0.5 units/kg/day e.g. 60 kg woman Type 1 ___ units/day e.g. 100 kg man Type 2 ___ units/day Basal (40% TDD) 12

Unknown starting dose

Write orders

Basal coverage Correction factor

Basal insulin 12 units/day

Humulin BASAL N Novolin NPH Levemir Sanofi Lantus Onset (h) 2 2 2 Peak (h) 6-8 Duration (h) 12-20 16-20 20-24

Subcutaneous N/NPH
40%

AM 60% HS 25% q6h 33% q8h

Levemir/Lantus
100%

5 units AM 7 units HS 3 units q6h 4 units q8h 12 units hs 0.5 units/hour

HS

Intravenous drip

Case #3

Humulin N 5 units AM 7 units HS Humalog correction factor 100/TDD 100/30 = 3

Rapid insulin correction (units) None 1 2 3 4 5 and call MD

Blood glucose (mmol/L) 4.0-9.0 9.1-12.0 12.1-15.0 15.1-18.0 18.1-21.0 > 21.0

Case #3
Breakfast Blood sugar Humulin N Humalog Correction 12.4 5 +2 Lunch 10.1 +1 Dinner 13.6 +2 Bedtime 8.9 7 0

Required 5 units of Humalog correction Can increase basal insulin by 4 units Humulin N 7 units AM 9 units HS

Case #3

Once eating: If Cr back at baseline

Restart

oral medications

If

Cr remains high
Add

Bolus insulin

Case #4

58F scheduled for total thyroidectomy for multinodular goitre Type 2 DM for 10 years A1c 7.3% Metformin 1g bid Humulin Mix 25 60-0-40-0

Write orders

Basal coverage Correction factor

Ensuring basal coverage

Usual DM regimen Oral agents only Oral agents + bedtime N Oral agents + bedtime Lantus or Levemir Mixed insulin BID MDI with bedtime N MDI with am and bedtime N MDI with Lantus or Levemir Insulin pump e.g. Humalog Mix 25 60-0-40-0 TDD = ___ units/day 20% TDD = ___ units N in am Basal coverage for AM of surgery Hold until eating Usual dose of bedtime N Usual dose of bedtime Lantus or Levemir 20% of TDD as morning N Usual dose of bedtime N 70% of am N Continue usual dose Continue basal rate

Ensuring basal coverage

Usual DM regimen Oral agents only Oral agents + bedtime N Oral agents + bedtime Lantus or Levemir Mixed insulin BID MDI with bedtime N MDI with am and bedtime N MDI with Lantus or Levemir Insulin pump e.g. Humalog Mix 25 60-0-40-0 TDD = 100 units/day 20% TDD = 20 units N in am Basal coverage for AM of surgery Hold until eating Usual dose of bedtime N Usual dose of bedtime Lantus or Levemir 20% of TDD as morning N Usual dose of bedtime N 70% of am N Continue usual dose Continue basal rate

Correction factor (100/TDD)

TDD = 100 then CF = 1

Rapid insulin correction (units) None 2 4 6 8 10 12 14 and call MD

Blood glucose (mmol/L) 4.0-8.0 8.1-10.0 10.1-12.0 12.1-14.0 14.1-16.0 16.1-18.0 18.1-20.0 > 20.1

Case #5

78M POD 5 hip fracture ORIF Type 2 diabetes Metformin 1000mg BID Glyburide 10mg BID Continuous NG feeds - swallowing concerns BS on oral meds 14-18 mmol/L

Write orders

Basal coverage Correction factor

Case #5

Start correction factor estimate TDD of 30 units CF = 3

Rapid insulin correction (units) None 1 2 3 4 5 and call MD

Blood glucose (mmol/L) 4.0-9.0 9.1-12.0 12.1-15.0 15.1-18.0 18.1-21.0 > 21.0

Case #5
06:00 Blood sugar Metformin + Glyburide Humalog Correction

12:00 15.7 9 9 +3

18:00 16.1 9 9 +3

00:00 13.5 9 9 +2

15.3 9 9 +3

Required 11 units of Humalog correction/day Can start basal insulin

Humulin

N 3-3-3-3 OR

Increase

CF to 1:2

Outline

Background and evidence Approach to the perioperative patient with DM

The

patient The treatment The surgery

Case discussions