Perioperative Care of the Elderly Patient
with Endocrine Problem
(Diabetes Mellitus and Thyroid disorders)
Dyah Purnamasari
Division of Endocrinology & Metabolism Department of Internal Medicine
Faculty of Medicine Universitas Indonesia/ Cipto Mangunkusumo Hospital
Jakarta 2019
Outline
• Perioperative management in DM
• Introduction
• Patophysiology
• Special consideration during perioperative glucose control in older adults
• Perioperative care (pre, intra and post op)
• Nutrition
• Pharmacotherapy
• Monitoring
• Perioperative management in Thyroid disorder
• Hypothyroid
• Hyperthyroid
• Take home message
Hyperglycemia and postoperative complication
• Perioperative hyperglycemia is reported in 20 to 40% of patients undergoing
general surgery and approximately 80% of patients after cardiac surgery
• However, 12 to 30% à do not have a history of diabetes before surgery (stress
hyperglycemia) à 30 and 60% of these patients have impaired carbohydrate
intolerance after hospital discharge (OGTT)
• Measurement of HbA1c in patients with hyperglycemia during hospitalization à
differentiate between stress hyperglycemia from undiagnosed DM
• The relationship between hyperglycemia and stress is well established, with
higher rates of 1) infection, 2) delayed wound healing, 3) neurologic injuries,
and 4) postoperative mortality.
• Gandhi et al. found a 30% increase in rate of adverse postoperative events for
every 20 mg/dL increase in intraoperative glucose level
Vaan den boom. Diabetes Care 2018
Duggan et al. Anesthesiology 2017
Increased mortality with increasing mean BG
after CABG (coronary artery bypass)
Furnary et al. J Thorac Cardiovasc Surg. 2003;125:1007-1021.
More complication in patients with diabetes
after non-cardiac surgery
Frisch, et al. Diabetes Care 2010; 33: 1783-1788
Perioperative glycemic control, but not A1C
predicts 30-day mortality post-surgery
An elevated preoperative A1C was not predictive of increased 30-day mortality
(noncardiac and cardiac surgery) after controlling for BG, despite the strong positive
association between A1C and average perioperative glucose.
àperioperative glycemic control may neutralize
the effect of high A1C on postoperative mortality
Vaan den boom. Diabetes Care 2018
Patophysiology of Accelerated Hyperglycemia in Surgery
Duggan EW, Carlson K, Umpierrez GE. Anesthesiology 2017
Common questions
1. What are the special consideration during perioperative glucose
control in older adults?
2. How low the glucose target during the perioperative periode?
3. How to prepare preoperative and postoperative periods?
4. How to manage nutrition in perioperative periode?
5. How to manage oral antidiabetic or insulin during pre, intra and
post operative period?
6. How is the optimal protocol for achieving BG in perioperative
period? Which is the preferred route of insulin therapy, SC or IV?
Special consideration during perioperative glucose control in
older adults
1. Vulnerable to developing hypoglycemia due to age-associated
reduced hypoglycaemia counter-regulatory homesotasis
- decreased β-adrenergic receptor function
- reduced glucagon response to hypoglycemia
- reduced GH responses to glucagon with aging
- epinephrine and cortisol responses are similar or reduced in older adults with
diabetes
2. Reduced renal function
- renal function à change rapidly once acutely ill or on multiple medications
- A higher risk of hypoglycemia due to renal insufficiency
- At greater risk of developing ileus and delirium postoperatively
Lee P, Min L, Mody L. Curr Geri Rep 2014
Perioperative glucose control in older adults
3. Increased awareness is necessary for older patients with
postoperative delirium or with pre-existing dementia
- disorientation and decreased attention due to delirium à distract
from proper medical detection of hypoglycemic symptoms
- advanced dementia à not be able to communicate their symptoms
or needs (symptoms of hypoglycemia or hunger) to physician
- ~ ¼ of older pts with DMT2 à have cognitive impairement
- Previous cognitive impairement or undiagnosed cognitive
impairement à increased risk of delirium
Lee P, Min L, Mody L. Curr Geri Rep 2014
Perioperative glucose control in older adults
4. Multimorbidity (2/> chronic conditions) is common in older adults.
- 2/3 of Medicare beneficiaries have 2/> chronic diseases, and
- 43 % have three or more.
- The presence of comorbidities such as diabetes, CKD, autonomic
neuropathy, dementia, and/or cognitive impairment à complicate
both management of glucose levels and detection of hypoglycemia
Close monitoring and less tight of glycemic target
Perioperative hydration strategies
Lee P, Min L, Mody L. Curr Geri Rep 2014
More tight BG control, more frequent BG monitoring
Preoperative periode
1. Fasting and Nutrition
• An important component of the preoperative evaluation
• Nutritional support, with dextrose containing solutions, may be
considered among DMT2 pts who get long acting insulin or SU during
fasting period
• Prolonged fasting is avoided in patients with diabetes. (usually 6-8 hr)
• Low carbohydrate diets facilitate insulin dosing and improved glucose
control.
• The metabolic needs for most hospitalized patients can be supported
by providing 25 to 35 calories/kg/day.
Preoperative periode
2. Preoperative glucose management
• Determine preop medication use and dose based on
• Type of diabetes,
• duration of the surgical procedure,
• length of pre- and postoperative fasting,
• type and frequency of daily medication, and
• state of metabolic control preceding surgery
Duggan et al. Anethesiology 2017
Preoperative periode
2. Preoperative glucose management… cont
• Prandial insulin is stopped when the fasting state begins.
Duggan et al. Anethesiology 2017
Intraoperative periode
Glucose management (SC vs IV route)
1. SC route
• Corr dose can be calculated àBG - 100/insulin sensitivity factor.
• Insulin sensitivity factor à1,800/patient’s total daily dose (TDD) of
insulin. Or ”40” for pts w oral drug at home
Duggan et al. Anethesiology 2017
Choosing administration of insulin therapy in perioperative periode
SUBCUTANEOUS INTRAVENOUS
PREOPERATIVE PREOPERATIVE
• minimally invasive procedure • Emergency/ uncontrolled BG
• expected hemodynamic stability • anticipated hemodynamic changes
• allow early resumption of oral intake • significant fluid shifts
• Short surgery/ procedure time • expected changes in temperature
POSTOPERATIVE • use of inotropes
noncritically ill, non-ICU surgical • lengthy operative times (greater than 4 h)
POSTOPERATIVE
• Prolonged fasting time
• Critically ill, ICU
These variables alter SC insulin absorption and distribution.
Unreliable pharmacokinetics àpersistent hyperglycemia or sudden hypoglycemia.
PERIOPERATIVE BLOOD GLUCOSE MONITORING
4-6 hourly 1-2 hourly
SC route IV route
Subcutaneous Insulin correctional dose protocol
Intraoperative periode
2. IV Route
Intravenous Insulin protocol à glucose level vs changes in glucose level
Changes in
glucose level
Glucose
level
Human resource !
1
Algorithm of
perioperative
management
Postoperative periode
1. Critically ill vs Non critically ill
• Critically ill à IV route
• Non criticall à SC route
2. Poor vs good oral intake
• Poor intake/ parenteral nutrition à IV route
• Good nutritional intake à SC route
POSTOPERATIVE INSULIN THERAPY PROTOCOL
POSTOPERATIVE INSULIN THERAPY PROTOCOL
TRANSITION FROM INTRAVENOUS TO SUBCUTANEOUS INSULIN THERAPY
IV insulin protocol
IV + SC insulin protocol
Critically ill period à non-critically ill
Stable hemodynamic
Patient able to accept nutrition by mouth or NGT
PERIOPERATIVE MANAGEMENT OF THYROID DISORDERS
Epidemiology
• It has been estimated that 90% of thyroid glands in women over the
age of 70 will contain nodules and 80% of the glands of men over the
age of 80 will be nodular.
• The incidence of thyroid cancer also increases with age
• Elderly patients often present with more aggressive forms of thyroid
cancer, larger tumours, more extensive local growth, or distant
metastases
• Because of an elevated risk for perioperative morbidity among elderly
patients undergoing surgical procedures, indications for
thyroidectomy in this population are often restricted to overt
compressive symptoms or a strong suspicion for malignancy
Types of Patients
Elderly patients who undergo surgery for thyroid problem
OR
Elderly patients with thyroid disease who undergo surgery for non-
thyroid problem
No sign of thyrotoxicosis and hypothyroid
Thyroid function test ??
PERIOPERATIVE SCREENING FOR THYROID DISORDERS
à without previous thyroid disorder
Palace MR. Health Service Insight 2017
PERIOPERATIVE SCREENING FOR THYROID DISORDERS
à with thyroid disorder
LABORATORIUM PARAMETER
HYPOTHYROID THYROTOXICOSIS
NORMAL TSH VALUE NORMAL FT4 VALUE
(TSH < 10 mU/L)
Palace MR. Health Service Insight 2017
PERIOPERATIVE COMPLICATIONS OF THYROID DISORDERS
HYPOTHYROIDISM HYPERTHYROIDISM
• Hypotension under anesthesia • Cardiac arrhythmias
• Ventilatory dysfunction • Fever
• Fluid & electrolyte disturbances • Gastrointestinal disturbances
• ↓clearance of anesthetics, tranquilizers & narcotics • Thyroid storm
• Post-operative ileus • High output heart failure
• Anemia • Mental status changes
• Myxedema coma
COMPLETE EVALUATION OF OTHER ORGAN SYSTEMS:
CARDIOVASCULAR, RESPIRATORY, KIDNEY FUNCTION, MENTAL STATUS ETC
Palace MR. Health Service Insight 2017
PERIOPERATIVE MANAGEMENT:
HYPOTHYROIDISM
• The pathophysiologic changes associated with hypothyroidism are
generally reversible with replacement of thyroid hormone.
• Preferable to postpone elective surgery until achieved euthyroidism.
• Urgent/ emergency surgery à mild or moderate hypo can be proceed
• A full replacement dose of levothyroxine is usually 1.6 μg/kg/day.
àelderly or had CAD history, the initial dose is usually 25 μg daily,
• Once TSH values normalize surgery can be performed.
• If oral medications cannot be given post-operatively, the dose may be
missed for several days. LT4 has a long half-life of approximately 7
days.
Palace MR. Health Service Insight 2017
PERIOPERATIVE MANAGEMENT:
HYPOTHYROIDISM
• Although elective surgery is best postponed until a euthyroid state is
achieved, patients requiring urgent or emergent surgery may proceed
with surgery if they have mild or moderate hypothyroidism (TSH < 10
mU/L)
• If emergent surgery is required, thyroid hormone levels should be
normalized as rapidly as possible, using IV levothyroxine in a loading
dose of 200 to 500 μg followed by 50 to 100 μg IV daily
Palace MR. Health Service Insight 2017
PERIOPERATIVE MANAGEMENT:
HYPERTHYROIDISM
• Atrial fibrillation occurs in 10% to 15% of patients with overt
hyperthyroidism subclinical hyperthyroidism (à THE MOST COMMON) à
Optimal treatment for AF: beta blocker, ca channel blocker
• Preferable to postpone elective surgery among patient with overt
hyperthyroidism (lab +, symptoms+, signs+)
• Urgent/ emergency surgery à cardiac status closely monitored
• If not possible to postpone the surgery:
• B blocker (selective/ non selective) or ca channel blocker
• Thionamide (PTU 100-150 mg every 6-8 h or methimazole 20-30 mg/d)
• Potassium Iodid 3x/d @ 3-5 drops (< 10 d preoperative) à after thionamid
adiministered
• Glucocorticoid à preoperatively and tapered over 3 days postoperatively.
(hydrocortisone 3x100 mg orally or IV, dexamethasone 4x2 mg orally or IV or beta-
methasone 4x0.5 mg orally, intramuscular, or IV).
Palace MR. Health Service Insight 2017
PERIOPERATIVE MANAGEMENT:
HYPERTHYROIDISM
• Thyrotoxicosis due to exogenous thyroid hormone intoxication à no
role of ATD, stabilize cardiovascular status (symptomatic)
• Thyrotoxicosis due to thyroiditis à no role of ATD, anti inflammation
• Glucocorticoid and Iodium à all types of thyrotoxicosis à decrease
conversion T4 to T3
• Thyroidectomy à Calcium and vitamin D postoperative
Palace MR. Health Service Insight 2017
TAKE HOME MESSAGE
• Perioperative hyperglycemia gives serious comorbidities
• BG target during perioperative is less than 180-200 mg/dL
• Among elderly à close monitoring (cardiac) and less tight glycemic
target
• In overt hypothyroid or hyperthyroidism à postpone surgery
• Urgent/ emergency à
• mild or moderate hypo can be proceed
• Preparation for overt hyperthyroidism à b blocker, thionamid, potassium
iodide and glucocorticoid
THANK YOU