Bariatric Times

MAR 2016

A peer-reviewed, evidence-based journal that promotes clinical development and metabolic insights in total bariatric patient care for the healthcare professional

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26 News and Trends Bariatric Times • March 2016 p atients who developed DKA within 90 days following bariatric surgery, at a median of 12 days. Eight of the patients had type 1 diabetes and four had type 2 diabetes. T hose numbers corresponded to incidences of 25% of the 32 total type 1 patients who underwent bariatric surgery during the study period and 0.2% of the a pproximately 3000 total type 2 patients. Most of the DKA in the type 1 patients was moderate to severe, while in the type 2 patients it was m ilder, Dr Aminian noted. All but one of the patients were taking insulin prior to surgery, and all had poor glycemic control, with a median HbA1c of 9.3%. Three p atients had a past history of DKA, and one developed DKA twice postsurgery. Nausea, vomiting, and abdominal pain were the most common presenting symptoms. I nadequate insulin therapy or noncompliance was the precipitating factor in eight of the 12 cases. In three of these, DKA developed in the immediate postoperative period in the hospital, possibly due to a combination of insulin undertreatment and surgical stress. In some of these cases, patients had been inappropriately instructed by a member of the surgical team to withhold basal insulin the morning o f surgery, Dr Aminian noted, adding that all team members have since been educated about the need for insulin optimization prior to surgery. Infection was a precipitating factor for DKA in four (33%) of the patients, and poor oral intake could have been a contributing factor in t hree (25%) patients. All patients were medically managed with insulin infusion. Two required intubation and mechanical ventilation, two experienced acute k idney injury, and one each had deep vein thrombosis, aspiration pneumonia, and iatrogenic pneumothorax. None died. Six Key Points to Reduce R isk of DKA in Bariatric Surgery. Based on this experience, Dr Amanian and colleagues have devised six key points applying to a ll insulin-treated patients undergoing bariatric surgery: • High risk patients — particularly poorly controlled patients with type 1 diabetes — should be informed about warning symptoms, signs, and predisposing factors of postoperative DKA. • These predisposing factors include anesthesia and surgical stress, abrupt discontinuation of insulin or inadequate treatment i n the perioperative period, postoperative infection, prolonged poor oral intake, and severe dehydration. • Preventive measures include o ptimizing glycemic control before surgery, not withholding basal insulin on the morning of surgery, and keeping the patients on insulin intravenous infusion p rotocols in the perioperative period. • Endocrinologists and diabetes nurse practitioners should be involved in the adjustment of b asal insulin dosage before surgery when the patient is on a low-calorie diet (usually beginning 2 weeks prior) and also in the immediate p ostoperative period and after hospital discharge. Insulin dose adjustment may also be necessary if infection develops postsurgery. • Recognition that postbariatric surgery DKA can cause abdominal pain, nausea, and vomiting should prevent unnecessary imaging studies to rule out intra-abdominal surgical complications such as leaks or abscess. • Early detection and aggressive diabetes care are needed to treat this serious adverse event. T o read the full article from medscape, visit http://www.medscape.com/viewartic le/858538. T o download the article published in Diabetes Care, visit http://care.diabetesjournals.org/cont ent/early/2016/01/26/dc15- 2647.full.pdf+html IS YOUR BARIATRIC CENTER ACCREDITED? UNIQUE? DO YOU HAVE A UNIQUE CASE TO SHARE? BARIATRIC TIMES IS SEEKING SUBMISSIONS! Contact Angela Saba at asaba@matrixmedcom.com for information on how to be featured in an upcoming installment of the Bariatric Center Spotlight or to submit your Case Report today. ALSO ACCEPTING VIDEO CLIPS WITH SUBMISSIONS. If accepted, your video clip could be included in the Bariatric Times digital edition.

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