آمادگی قبل و بعد از عمل جراحی بیماران مبتلا به دیابت

Hospital Diabetes Management (ADA 2026) Dr. Alireza Arefzadeh Assistant Prof of Endocrinology Farhikhtegan Hospital Tehran Medical Sciences Islamic Azad University Importance of Inpatient Diabetes Management • - Hyperglycemia, hypoglycemia, and glucose variability increase surgical risks • - Associated with higher morbidity, mortality, longer hospital stays • - Impacts readmission rates and healthcare costs Risks of Poor Control of Blood Sugar Surgical site infections Cardiovascular events Delayed wound healing Longer hospital stays and higher mortality Pathophysiology of the effect of Surgery on Blood Sugar Surgical stress response: cortisol, catecholamines, glucagon, growth hormone Increased glucose production and insulin resistance Preoperative Management Patient evaluation: history, medications, comorbidities Adjust oral hypoglycemics and insulin regimens Target glucose range: 80–180 mg/dL Consider basal or IV insulin for tighter control Admission: A1C Testing • - Perform A1C at admission if no result in past 3 months • - Helps assess preadmission glycemic control • - Guides inpatient and discharge planning Identify Diabetes Type • - Type 1, Type 2, gestational, pancreatogenic, stress, drug/nutritionrelated • - Important for treatment approach Assess Self-Management & Education • - Evaluate patient’s knowledge and behaviors • - Provide education during stay, especially with new treatment plans Plan Perioperative Glycemic Control • - Develop individualized plan • - Coordinate with surgical and anesthesia teams • - Consider nutrition, medications, and stress response When to Start Insulin • - Persistent hyperglycemia ≥180 mg/dL (≥10.0 mmol/L) on 2 occasions in 24h • - Applies to both ICU and non-ICU patients ICU Glycemic Targets • - Goal: 140–180 mg/dL (7.8–10.0 mmol/L) • - More stringent goals (110–140 mg/dL) for select patients if safe Non-ICU Glycemic Targets • - Goal: 100–180 mg/dL (5.6–10.0 mmol/L) • - Avoid hypoglycemia; adjust for comorbidities Risks of Hypoglycemia • - <70 mg/dL: Level 1 • - <54 mg/dL: Level 2 (neuroglycopenic) • - <40 mg/dL: Level 3: Requires assistance • - Avoid aggressive insulin in high-risk patients Insulin Pump Use in Hospital • - Continue if clinically appropriate • - Requires supplies, training, and protocols Automated Insulin Delivery (AID) • - Hybrid closed-loop systems may be continued • - Ensure CGM accuracy and staff oversight Safety and Staff Training • - Train staff on device use and troubleshooting • - Monitor CGM and AID data daily IV Insulin in Critical Care • - Preferred method for ICU patients • - Use validated protocols for titration Basal + Correction Insulin with poor/no oral intake • - For non-ICU patients with poor/no oral intake • - Prevents large glucose fluctuations Basal + Prandial + Correction • - For patients with adequate oral intake • - Mimics physiologic insulin secretion Sliding Scale Alone • - Correction-only insulin without basal is discouraged • - Exception: • 1)mild hyperglycemia in non-ICU patients • 2) Lack of sufficient staff or lack of awareness among nurses or small number of staff Transition from IV to Subcutaneous • - Overlap basal insulin 2h before stopping IV • - Prevents rebound hyperglycemia Dosing Strategies • - 0.3–0.6 units/kg/day • - Adjust for insulin sensitivity, prior dose, or infusion rate Preventing Rebound Hyperglycemia • - Use basal insulin during transition • - Monitor closely and adjust as needed Stopping Oral Agents • - Discontinue during acute illness or surgery • - Risk of lactic acidosis (e.g., metformin), hypoglycemia Restarting Medications • - Resume when stable and eating • - Consider DPP-4 inhibitors for mild hyperglycemia Restarting Home Insulin Plans • - Assess adherence and clinical status • - Adjust for nutrition, kidney function, medications Discharge Planning • - Provide education on insulin use, glucose monitoring • - Ensure access to medications and supplies • - Schedule outpatient follow-up Perioperative Management of Oral Antidiabetic Agents Importance • • Risks of continuing oral agents during surgery: • • • - Hypoglycemia - Lactic acidosis - Drug interactions Metformin • • Stop 24–48h before surgery • • Risk: lactic acidosis • • Restart when renal function and oral intake are stable Sulfonylureas • Generally Stop the day before surgery • Generally, treatment with sulfonylureas can be continued the day before surgery; however, we recommend discontinuing these medications sooner if the patient is expected to follow a lowcarbohydrate diet for several days before the procedure (eg, before bariatric surgery). • • Risk: hypoglycemia • • Restart when eating resumes SGLT2 Inhibitors • • Stop 3–4 days before surgery • • Risk: euglycemic diabetic ketoacidosis (DKA) • • Restart when stable and well hydrated DPP-4 Inhibitors • • May continue until surgery • • Can be restarted early post-op • • Useful for mild hyperglycemia GLP-1 Receptor Agonists • • Hold on day of surgery • • Risk: nausea, vomiting • • Restart when gastrointestinal function is normal Thiazolidinediones • • Stop before surgery • • Risk: fluid retention, heart failure • • Restart cautiously post-op Restarting Oral Agents • • Criteria for restarting: • • • - Stable hemodynamics - Adequate renal/hepatic function - Resumed oral intake Pre-Surgery Protocols: Step 1 • • Assess A1C if not done in past 3 months • • Identify diabetes type (T1DM, T2DM, others) Pre-Surgery Protocols: Step 2 • • Stop oral antidiabetic agents as per protocol Pre-Surgery Protocols: Step 3 • • Initiate basal insulin if not already on insulin • • Consider dose adjustments based on glucose trends Pre-Surgery Protocols: Step 4 • • Educate patient on fasting and insulin plan • • Coordinate with surgical and anesthesia teams Night Before Surgery: Step 1 • • Reduce basal insulin dose by 20–30% • • Hold prandial insulin if patient is fasting Night Before Surgery: Step 2 • • Monitor blood glucose overnight • • Target range: 100–180 mg/dL Night Before Surgery: Step 3 • • Prevent nocturnal hypoglycemia • • Adjust insulin if exist hypoglycemia events Night Before Surgery: Step 4 • • Ensure availability of dextrose if needed • • Communicate plan with nursing staff Surgery Day: Step 1 • • Withhold prandial insulin • • Continue reduced basal insulin Surgery Day: Step 2 • • Initiate IV insulin infusion if glucose ≥180 mg/dL • • Use validated insulin infusion protocols Surgery Day: Step 3 • • Monitor glucose every 1–2 hours • • Maintain target: 140–180 mg/dL Surgery Day: Step 4 • • Adjust insulin infusion based on trends • • Avoid hypoglycemia (<70 mg/dL) Post-Surgery: Step 1 • • Transition from IV to subcutaneous insulin • • Overlap basal insulin 2 hours before stopping IV Post-Surgery: Step 2 • • Calculate total daily insulin dose: 0.3– 0.6 units/kg/day • • Split into basal and prandial components Post-Surgery: Step 3 • • Adjust insulin for nutrition intake • • Consider renal function and steroid use Perioperative adjusted dose of Insulin for patients under treatment with Insulin • Patients on home insulin therapy should decrease the dose of longacting basal insulin (glargine and detemir) from 20% to 30% the evening before surgery. Perioperative adjusted dose of Insulin for patients under treatment with Insulin • Patients on twice-daily glargine or detemir should reduce the dose by 20% to 30% the evening before the morning of surgery and on the morning of surgery. Perioperative adjusted dose of Insulin for patients under treatment with Insulin • Patients who administer high doses of basal insulin (>60% of total daily dose (TDD) of insulin), have a TDD of insulin exceeding 80 units, or have a high risk of hypoglycemia (eg, older populations, those with renal or hepatic insufficiency, or those with a history of hypoglycemic episodes) should reduce their basal insulin dose by 50% to 75% to minimize the risk of hypoglycemia. Perioperative adjusted dose of Insulin for patients under treatment with Insulin • In cases of intermediate-acting insulin such as neutral protamine Hagedorn (NPH), the usual dose is administered the evening prior and reduced by 50% on the morning of surgery. Perioperative adjusted dose of Insulin for patients under treatment with Insulin • Patients using premixed insulin (NPH/regular 70/30 or aspart protamine/aspart 75/25) should preferably receive long-acting insulin the evening before surgery instead of their premixed formulation. • In situations where this is not feasible, the premixed insulin should be reduced by 50% on the morning of surgery, and dextrose-containing intravenous solutions should be initiated. • Another option for these patients is to skip the morning dose and arrive early at the preoperative area to receive a long-acting formulation before surgery Summary • Structured insulin protocols • reduce perioperative risks • Improve glycemic control and surgical outcomes • Ensure coordination among care teams • Improves outcomes and reduces readmissions