Perioperative Management in

Patients with Diabetes and

Management of Steroid Induced
Hyperglycemia

Dyah Purnamasari
 Outline

1. Perioperative management in DM
✓ Perioperative care (pre-, intra-, and post-surgery)
Nutrition
Pharmacotherapy
Monitoring
2. Steroid induced hyperglycemia
3. Take home message
 Predictors of Stress Hyperglycemia During Surgery

Surgical Perioperative Patient factors

• More invasive procedure • GC • Degree of illness

(open vs laparoscopic)
• Parenteral/ enteral nutrition • Pre-existing state of
• Anatomic location involving IR/deficiency
thorax and abdomen • Physical inactivity
• Advanced age
• General anesthesia (vs
epidural) • Higher BMI

• Intraoperative fluids with • Higher HbA1c

>5% dextrose
• Baseline BG level on D0

Palermo NE et al. Curr Diab Rep 2016

 Pathophysiology

Galindo RJ et al.
Endocrinol Metab Clin North Am 2018
 Comprehensive Care Pathway for Perioperative
Management of Diabetes

The time period that begins when the decision for surgery is
made until the patient is transferred to the operation room

The time which is start from the admission into the recovery area and
continues until the patient is discharged from the care of the surgeon

Primary care Pre-operative Theatre Discharge

referral assessment and recovery

Surgical Hospital Post operative

outpatients admission Care

The time period from which the patient is transferred to the operation table and
continues till the patient transferred to the post-operative recovery area

TARGET BLOOD GLUCOSE: 140 – 180 MG/DL

Levy, N.,et al. British Journal of Anaesthesia. (2016). 116(4), 443-447. doi:10.1093/bja/aew049
 PREOPERATIVE PERIODE

Pre-operative evaluation
❑ Type of diabetes,
❑ Type and frequency of daily medication,
❑ Metabolic control preceding surgery (nutrition, fluid/ electrolyte, BG)
❑ Vascular status: cardiac, renal, cerebral; or presence of diabetic complications that
may adversely affect by/ during the procedure
❑ Type of surgery:
• emergency/ elective,
• major/ minor procedure
• Type of anaesthesia
❑ Length of pre- and postoperative fasting
❑ Identify high risk patients requiring critical care management post operatively

Duggan et al. Anethesiology 2017

 PREOPERATIVE PERIODE

1. Fasting and Nutrition

• Nutritional support (dextrose containing solutions) during fasting period/ once the patient has
at least 1 missed meal→ especially DMT2 patients who get long acting insulin or SU
• Prolonged fasting is avoided in patients with diabetes. (usually 6 hr)
• Procedure should be done at the first round to avoid prolonged fasting.
• Low carbohydrate diets → insulin dosing and improved glucose control.
• The metabolic needs for most hospitalized patients can be supported by providing 25 to 35
calories/kg/day.
• Patients undergoing bowel investigations and radiological and other imaging procedures that
involve a period of fasting or the administration of radio-contrast also undergo same
preparation regarding nutritional support and antidiabetes adjustment

Duggan et al. Anethesiology 2017

 PREOPERATIVE PERIODE

2. Preoperative glucose management: elective procedure Nutrition

Profile of random/fasting venous/capillary blood glucose level

Good glycemic control Major surgery/ Bad glycemic control

Predicted ICU post op
Prolong fasting
Minor surgery
Duration op < 4 hr
Normal oral intake in the same day SC basal bolus
insulin regimen
Continue recent antidiabetic regimen (eating) → failed →
Follow regulation of antidiabetic drugs (oral and injection) H-1 & H-0* IV Insulin protocol**
BG monitoring every 4-6 hr during fasting
 PREOPERATIVE PERIODE

2. Preoperative glucose management: oral antidiabetic drug*

D-0 (day of surgery) D-0 (day of surgery)
Normal oral intake in the same day/ Reduced post-op oral intake; extensive
OAD D-1 surgery; HD change/ fluid shifts
minimally invasive surgery

Sulfonylureas + - -
Metformin +* +* -
Thiazolidinediones + + -
Alpha glucosidase + + -
inhibitor
GLP-1 agonists + - -
DPP-4 inhibitors + + -
SGLT2 inhibitors - - -

* Hold if use IV contrast

SU → risk of hypoglycemia; Alpha glucosidase inh → no effect during fasting; TZD → risk of fluid retention, Metformin → if renal complication happen during
surgery ~ risk of lactic acidosis, GLP-1 agonists → delay proper GI function post-op, DPP-4 inh → primarily effect after meal, minimal effect during fasting,
SGLT2 inh → risk of euglycemic DKA, dehydration
Duggan et al. Anethesiology 2017
Sudhakaran S et al. Surgery research & practice 2015
 PREOPERATIVE PERIODE

2. Preoperative glucose management: insulin therapy*

▪ Sc prandial insulin is stopped when the fasting state begins.

▪ Sc basal insulin is continued at H-1:

• In general → at the same dose
• Consider ↓ dose if previous FBG < 100 mg/dL or there are risks of hypoglycaemia
• ↓ dose ~ 20-30% according to risk of hypoglycaemia

▪ If patient using sc basal insulin:

• Consider nutritional parenteral iv after 4-6hr fasting or if BG level <100-140 mg/dL, example:
dextrose 5%; 10%

▪ BG monitoring every 4-6 hr during fasting

 PREOPERATIVE PERIODE

2. Preoperative glucose management: elective procedure

Profile of random/fasting venous/capillary blood glucose level

Good glycemic control Major surgery/ Bad glycemic control

Predicted ICU post op
Prolong fasting
Minor surgery
Duration op < 4 hr
Normal oral intake in the same day
SC basal bolus
insulin regimen
Continue recent antidiabetic regimen (eating) → failed →
Follow regulation of antidiabetic drugs (oral and injection) H-1 and H-0* IV Insulin protocol**
BG monitoring every 4-6 hr during fasting
 PREOPERATIVE PERIODE

2. Preoperative glucose management: emergency procedure

Measure of random/fasting venous/capillary blood glucose level

Good glycemic control Bad glycemic control

DDM: NDM: Insulin iv protocol**

Continue recent antidiabetic regimen BG monitoring every 4-6 hr BG monitoring
Follow regulation of antidiabetic drugs Give insulin CD if needed*** every 1-4 hr
(oral and injection) H-1 and H-0*
BG monitoring every 4-6 hr

BG target not achieved

with CD
DDM: diagnosed DM; NDM: newly diagnosed DM; CD: correctional dose
 PREOPERATIVE PERIODE

2. Preoperative glucose management: emergency procedure

• CD*** can be applicable in non-severe hyperglycaemia (BG 180 - < 250 mg/dL) during
fasting periode
Insulin Sensitive* Insulin Resistant*
Blood Glucose Age > 70 yr, BMI > 35 kg/m2,
mg/dl (mM) GFR < 45ml/min Usual Insulin Home TDD Insulin > 80 U
No History of Diabetes Steroids > 20mg Prednisone Daily
141-180 (7.7-10) 0 2 3
181-220 (10-12.2) 2 3 4
221-260 (12.2-14.4) 3 4 5
261-300 (14.4 – 16.6) 4 6 8
301-350 (16.6-19.4) 5 8 10
351-400(>22.2) 6 10 12
>400 (>22.2) 8 12 14
*if the patient falls into more than one insulin treatment group, choose the category with the lowest correctional dose to minimize the risk of hypoglycemia.
BMI = body mass index; GFR = glomerular filtration rate; TDD = Total daily dose
 PREOPERATIVE PERIODE

2. Preoperative glucose management: Insulin iv protocol **

INDICATION
- emergency condition
- severe hyperglycemia (BG ≥ 250/300 mg/dL)
- uncontrolled BG after optimation basal bolus/ basal + correctional dose (CD) sc insulin
→ start insulin iv if BG ≥ 250/300 mg/dL

• Regular human insulin intravena → serum half life 7 minutes

• Dose initiation of insulin iv therapy

- based on current glycemic control OR
- DM1 → 0.5–1 U/hour
- DM2 → 2- 3 U/hour or higher

• Two types of IV insulin regimen

- Various Rate of Intravenous Insulin Infusion (VRIII) every 1-2 hr
- (fixed rate) IV insulin + CD SC insulin every 4-6 hr
 Insulin IV Titration (VRIII)**

Intravenous Insulin protocol → glucose level vs changes in glucose level

Changes in If BG Increased from Previous BG Decreased from Previous BG Decreased from Previous
glucose level BG mg/dl (mM) Measurement Measurement by Less Than 30 mg/dl Measurement by Greater Than 30 mg/dl

>241 (13.4) Increase rate by 3 U/h Increase rate by 3 U/h No change in rate
211-240 (11.7-13.4) Increase rate by 2 U/h Increase rate by 2 U/h No change in rate
181-210 (10-11.7) Increase rate by 1 U/h Increase rate by 1 U/h No change in rate
141-180 (7.8-10) No change in rate Decrease rate by ½ U/h No change in rate
110-140 (6.1-7.8) No change in rate Old insulin infusion
100-109 (5.5-6.1) 1. Hold insulin infusion
Glucose 2. 2. Recheck BG hourly
level 3. Restart infusion at ½ the previous infusion rate if BG > 180 mg/dl ( 10mM)
71-99 (3.9-5.5) 1. Hold insulin infusion
2. Check BG every 30 minutes until BG > 100mg/dl (5.5mM)
3. Resume BG checks every hour
4. Restart infusion at ½ the previous infusion rate if BG > 180mg/dl ( 10mM)
70 (3.9) or lower If BG = 50-70 (2.8-3.9mM),
1. Give 25 ml D50
2. Repeat BG checks every 30 min until BG > 100 mg/dl (5.5mM)
If BG = 50-70 (2.8mM),
1. Give 50 ml D50
2. Repeat BG every 15 min until > 70 mg/dl (3.9mM)
Human Resource ! 3. When BG > 70mg/dl, check BG every 30 min until > 100mg/dl (5.5mM). Repeat 50 ml D50
dose if BG < 50mg/dl a second time and start D10 infusion
4. After BG > 100mg/dl (5.5mM), resume hourly BG xheck
Restart infusion at ½ the previous infusion rate if BG > 180mg/dl (10mM)
 PREOPERATIVE MANAGEMENT

PREOPERATIVE ASSESSMENT
• Current metabolic status & glycaemic control
ELECTIVE SURGERY • Pre-existing comorbidities/ DM complications EMERGENCY SURGERY
• Types of surgery
• Risk of requiring critical care post-op

Nutrition & fasting BG monitoring Pharmacotherapy

* SC basal bolus/ * Various insulin

OAD basal + CD/ CD insulin rate iv insulin

GLYCAEMIC CONTROL 140 – 180 mg/dL

*Glycaemic target not achieved
 POSTOPERATIVE PERIODE

1. Categorize the patients whether they are

• Critically ill vs non critically ill
• Poor or good oral intake
• Non severe OR severe hyperglycemia

2. Critically ill or non critically-ill

Critically ill → IV insulin protocol is continued
Non critically ill → prefer SC route, if severe hyperglycemia happen → iv route

3. Poor vs good oral intake

Poor intake → maintain glucose/nutrition infusion
Good nutritional intake → stop glucose infusion after meal and resume antidiabetic agent (oral/sc insulin)

4. Non severe or severe hyperglycemia

non severe hyperglycemia BG 180- < 250 mg/dL : give CD***
severe hyperglycemia BG ≥ 250 mg/dL : start insulin iv protocol

5. Frequent BG monitoring depend on patient’s condition

Diabetes management expertise must be available for the post-operative
management of glycemic instability.
 POSTOPERATIVE INSULIN THERAPY PROTOCOL
Non-critically ill: NPO/poor oral intake
TDD for basal requirement Total Daily Dose
Insulin Resistant
Total Daily Dose BMI > 35 kg/m2,
Insulin Sensitive Total Daily Dose Steroids > 20 mg
Type of Insulin Age > 70 yr, GFR < 45 ml/min Insulin Usual Prednisone Daily

NPO/Poor oral Intake / Clear Basal (glargine/detemir) 0.1-0.15 U •kg-1 •day-1 0.2-0.25 U •kg-1 •day-1 0.2-0.25 U •kg-1 •day-1
liquid Diet
USE BASAL PLUS REGIMEN Correctional (rapid acting) Treat BG > 180 mg/dl (10mM) using correctional calculation or table 5

Insulin Sensitive* Insulin Resistant*

Age > 70 yr, BMI > 35 kg/m2
Blood Glucose GFR < 45 ml/min, Usual Home TDD Insulin > 80 U
mg/dl (mM) No History of Diabetes Insulin Steroids > 20mg Prednisone Daily

141-180 (7.7-10) 0 2 3
Corr dose can be calculated →
181-220 (10-12,2) 2 3 4
- (BG - 100)/insulin sensitivity factor.
221-260 (12.2-14.4) 3 4 5
Insulin sensitivity factor →1,800/patient’s
261-300 (14.4-16.6) 4 6 8
TDD of insulin
301-350 (16.6-19.4) 5 8 10
….. OR…… ”40” for pts w oral drug at home
351-400 (19.4-22.2) 6 10 12
>400 (>22.2) 8 12 14

*If the patients fall into more than one insulin treatment group, choose the category with the lowest correctional dose to
minimize the risk of hypoglycemia, BMI = body mass index; GFR = glomerular filtration rate; TDD = total daily dose.
 POSTOPERATIVE INSULIN THERAPY PROTOCOL
Non-critically ill: Normal Oral Intake
TDD for basal & prandial Total Daily Dose
requirement Insulin Resistant
Total Daily Dose BMI > 35 KG/M2,
Insulin Sensitive * Total Daily Dose Steroids > 20 mg
Type of Insulin Age > 70yr, GFR < 45ml/min Insulin Usual Prednisone Daily

Normal Oral Intake At Meals Basal (glargine/detemir) 0.1-0.15 U• kg-1 • day-1 0.2-0.25 U• kg-1 • day-1 0.35 U• kg-1 • day-1

USE BASAL BOLUS Prandial (rapid acting) 0.1-0.15 U• kg-1 • day-1 0.2-0.25 U• kg-1 • day-1 0.35 U• kg-1 • day-1

REGIMEN Orrectional (rapid acting) Treat BG > 180 mg/dl (10mM) using correctional calculation or table 5

*If the patients fall into more than one insulin treatment group, choose the category with the lowest insulin dose to minimize the risk
of hypoglycemia, BG – Blood Glucose; BMI = body mass index; GFR = glomerular filtration rate; NPO = nothing by mouth
 Hypoglycemia and Perioperative Complications

• Unmanaged hypoglycemia → neurological complications including somnolence,

unconsciousness, and seizures → irreversible neurological or death

• Hypoglycemia enhances morbidity/mortality in critically ill diabetic patients and can

prolong ICU/hospital stay

Overall, with the use of careful glucose management strategies,

the primary outcome measures of surgery are similar between
diabetic and nondiabetic patients

Vaan den boom. Diabetes Care 2018

Duggan et al. Anesthesiology 2017
MECHANISMS OF GLUCOCORTICOID-INDUCED HYPERGLYCEMIA

•DOI: 10.1016/[Link].2018.03.006
 Steroids Doses Bioequivalents

Steroid Potency Duration of action

(Equivalent doses) (half-life in hours)
Hydrocortisone 20 mg 8
Prednisolone 5 mg 16 – 36
Methylprednisolone 4 mg 18 – 40
Dexamethasone 0.75 mg 36 – 54
Betamethasone 0.75 mg 26 – 54
Nb . Potency relates to anti-inflammatory action, which may not
equate to hyperglycemia effect

J Support Oncol. 2006 Oct;4(9):479-83

J Support Oncol. 2006 Oct;4(9):479-83
 Predisposing Factors Leading to Increased Risk of
Hyperglycaemia with Steroid Therapy

1. Pre-existing type 1 or type 2 diabetes

2. People at increased risk of diabetes (e.g. obesity, family history
of diabetes, previous gestational diabetes, ethnic minorities,
PCOS).
3. Impaired fasting glucose or impaired glucose tolerance, HbA1c (6
-6.4 %).
4. People previously hyperglycaemic with steroid therapy.

Diabet Med. 2018 Aug;35(8):1011-1017. doi: 10.1111/dme.13675.

 Ten Key Facts About Steroid Diabetes
1. Primary effect is on postprandial glucose level.
2. Glucose values tend to normalize overnight.
3. Glucose levels should be tested before as well as 2 hours after a meal.
4. Oral agents are usually inappropriate, ineffective, or too inflexible.
5. Insulin is generally the best therapy.
6. Prandial insulin is the primary need.
7. Prandial insulin should be titrated to the glucose 2 hours post prandially (or the next meal).
8. Basal insulin should be given in the morning and titrated to the glucose level from the following
morning.
9. Target glucose levels are < 100 mg/dL pre-meal and 140–180 mg/dL 2 hours postprandially.
[Link] diabetes is difficult to control: consults with endocrinologists, certified diabetes
educators, and nutritionists are appropriate.

J Support Oncol. 2006 Oct;4(9):479-83

 Monitoring Guidance
• In people without a pre-existing diagnosis of diabetes
• Monitoring should occur at least once daily – preferably prior to lunch or
evening meal, or alternatively 1-2 hours post lunch or evening meal.
• If the initial blood glucose is < 200 mg/dl continue to test once prior to
or following lunch or evening meal
• If a subsequent capillary blood glucose is found to be ≥ 200 mg/dl ,
then the frequency of testing should be increased to 4 daily (before
meals and before bed)
• If the capillary glucose is found to be consistently > 200 mg/dl i.e. on two
occasions during 24 hours, then the patient should enter the treatment
algorithm

Diabet Med. 2018 Aug;35(8):1011-1017. doi: 10.1111/dme.13675.

 Use of Oral Antidiabetes

• Outpatients, mild hyperlgycemia (BG < 200 mg/dl)

• Short term steroid use
• Unable or unwilling to get injection therapy
• Bridging therapy → until diabetic education is complete
• Metformin → not first choice (side effect, comorbidities)
• SU/ glitazon/ DPP-4 inhibitor
• Short acting SU (glinid, gliklazid)
• Long acting SUs are not suitable for postprandial hyperglycemia, increase
risk of hypoglycemia
• Uncontrolled BG in 24-48 hr with OAD → insulin therapy, involve diabetes
team

J Support Oncol. 2006 Oct;4(9):479-83

 MANAGEMENT OF HYPERGLYCEMIA
GLUCOCORTICOID-INDUCED HYPERGLYCEMIA

RANDOM BLOOD SUGAR

200 – 250
< 200 mg/dL mg/dL
> 250 mg/dL

DIET DIET
DIET ALONE
SULFONYLUREA INSULIN (0.5 IU/Kg/day)

Fasting blood Fasting blood Adjust insulin to

Glucose < 140 mg/dL Glucose < 140mg/dL achieve fasting and
preprandial glucose <
140 mg/dL

Continue monitor Continue monitor Continue monitor

Joint British Diabetes Societies for Inpatient Care12 April 2016

 Management of diabetes with Management of diabetes without
insulin prior to hospitalization insulin prior to hospitalization

Total Daily Dose of Insulin

Continue the same treatment, until
two consecutive glucose Unit / Kg Glucose Level (mg/dL)
measurements above 200 mg/dL
0.5 200 -400

0.7 >400

Add meal – time correction factor 50% of TDD order as 50% of TDD order as
short acting insulin basal long acting insulin

Insulin Therapy 1–1.2 Units/Kg/Day, 25% Basal

Glucose level Units of And 75% Prandial receiving High-dose
(mg/dL) Insulin Dexamethasone
200 -250 2
250-300 3
300-350 4
> 350 Consult with
the Doctor Intern Med J, 45: 261-266. doi:10.1111/imj.12680
[Link]
BMC Endocr Disord 18, 75 (2018). Diabetes Technology & Therapeutics VOL. 16, NO. 12 |
 TAKE HOME MESSAGE

• BG target during perioperative is between 140-180/200 (elderly) mg/dL

• PERIOPERATIVE → preoperative, intraoperative, and postoperative

• Preoperative → assessment current condition and the risk of complications during and post-
operative; preparation include nutrition, duration of fasting and BG management

• Postoperative → re-assessment patient status (critically-ill or noncritically-ill; intake status)

• Treatment of steroid induced hyperglycemia should be based on blood glucose and
individualized
• Insulin is recommended as drug of choice for induced hyperglycemia by steroid especially in
acute condition
• Some cases can be managed by oral hyperglycemic agent
 No Known Diabetes
• Check HbA1c prior to the commencement of glucocorticoids in patients perceived to be at high risk
• On commencement of glucocorticoid, recommend capillary blood glucose (CBG) once daily pre or post lunch or evening meal
• If the CBG < 200 mg/dL consider the patient to be at low risk and record the CBG daily post breakfast or post lunch
• If CBG consistently < 180 mg/dL consider stop CBG testing
• If a CBG is found ≥ 200 mg/dl the frequency of testing should be increased to four (4x) times a day
• If a CBG is found to be consistently ≥ 200 mg/dL (i.e. on two occasions during a 24 hour period), then the patients should enter the
treatment algorithm below

If still no improvement on maximum dosage consider:

• Adding an evening dose of gliclazide or add morning human NPH/Glargine insulin
• For NPH/Glargine 10 units daily in the morning and titrate every 24 hours by 10-20% to achieve desired
CBG target

Discharge-monitoring will need to be continued in patients remaining on glucocorticoids post discharge

• If glucocorticoid treatment is ceased in hospital and hyperglycaemia has resolved CBG can be discontinued post
discharge
• If glucocorticoids are discontinued prior to discharge and hyperglycaemia persists the continue with monitoring until
normal glycaemia returns or until a definitive test for diabetes is undertaken (fasting blood glucose, OGTT or HbA1c)

• If glucocorticoids are reduced or discontinued:

− continue CBG testing if CBG > 200 mg/dL in 24 hours
− Any changes made should be reviewed and consideration given to reverting to previous therapy or doses
• If unsure at any stage about next steps or want specific advice on how to meet with patients needs or expectations
please discuss with the team who usually looks after their diabetes (GP/Specialist Team)

Glycaemic targets:
• Aim for 100 -180 mg/dL (acceptable range 70 – 200 mg/dL)
• End oflife care: aim for 100- 250 mg/dL an symptom relief
NPH=neutral protamine Hagedorn; OGTT: oral glucose tolerance test; HbA1c=glycated haemoglobin Joint British Diabetes Societies for Inpatient Care12 April 2016
 Known Diabetes, reassess glucose control and current therapy:
• Set target blood glucose e.g. 100 – 180 mg/dL (see glycaemic targets box below)
• Check capillary blood glucose (CBG) four times a day and use this flowchart to adjust diabetes medication accordingly
• In type 1 diabetes also check daily for ketones if CBG > 200 mg/dL

In type 1 diabetes, always test for ketones, if blood ketones are more than 3 mmol/l or urinary
Type 2 (diet controlled) or ketones >++ assess for DKA.
on OHA +/- GLP1 In type 2 diabetes check for ketones if CBG levels > 200 mg/dL and the patient has osmotic
symptoms

If no ‘hypo’ symptoms and QD night time insulin, BD insulin: Basal bolus insulin:
NOT on an SU: transfer this injection • Morning dose will need to • Consider transferring evening
• Gliclazide 40 mg am, titrate daily to the morning: increase 10-20% daily
basal dose insulin to the
according to pre-evening
until a maximum of 240 mg am, • Titrate by 10-20% daily
meal CBG readings
morning and increase
• Or If on BD gliclazide 240 mg according to pre-evening • Aim for CBGs to individual needs as short/fast acting insulin by 10-
meal CBG readings stated above, unless patient 20% daily until glycaemic
morning dose plus 80 mg pm • If targets not achieved experiences ‘hypo’ despite snacks
target reached
and targets not reached consider BD, or basal bolus • Aim for agreed CBGs target to patients needs
regimen premeal, unless patient has hypo despite
snacks or has long gaps between meals

If no ‘hypo’ symptoms and taking 320

If glucocorticoids are reduced or discontinued:
mg/day :
• Blood glucose monitoring may need to be continued in inpatients and, in discharged patients assessed by
• Add human NPH/Glargine insulin 10 their GP
IU and aim for CBG appropriate to • Any changes made should be reviewed and consideration given to reverting to previous therapy or doses
patients’ needs If unsure at any stage about next steps, or want specific advice on how to meet with patients needs or
expectations, please discuss with the team wo usually looks after their diabetes (GP/Specialist Team)

If CBG remains above desired target before Glycaemic targets:

the evening meal: • Aim acceptable range 70-200 mg/dL
• Increase insulin by 4 units or 10-20% • End of life care: aim for 100-250 mg/dL and symptom relief
• Review daily
• If remains above target, titrate daily by 10- SU=sulfonylurea; DKA=diabetic ketoacidosis; OHA=oral hypoglycaemic agents;GLP1=glucagon-like peptide-1
20% until glycaemic target reached
Joint British Diabetes Societies for Inpatient Care12 April 2016