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Management of Diabetes in Surgery

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Presentation on theme: "Management of Diabetes in Surgery"— Presentation transcript:

1 Management of Diabetes in Surgery

2 Diabetes Diabetes is a metabolic disorder resulting from insulin deficiency or intolerance Associated with acute and long term systemic problems Diagnosed by a random plasma glucose >11.1mmol/l and a fasting glucose>7.0mmol/l (WHO criteria) The two most common forms of diabetes are Insulin Dependant Diabetes Mellitus (Type 1) and Non Insulin Dependant Diabetes Mellitus (Type 2)

3 Type 1 Diabetes Mellitus
Polygenic disorder thought to be of auto immune aetiology Results in destruction of β cells in the Islets of Langerhans in the Pancreas, with subsequent insulin deficiency Young onset 0.4% prevalence Endogenous insulin is required to maintain plasma glucose levels to within physiological levels

4 Type 2 Diabetes Mellitus
Hypoglycaemia resulting from reduced insulin secretion and peripheral insulin resistance Some genetic concordance Older onset, associated with central obesity Depending on severity, may be controlled with: diet and exercise to lose weight oral hypoglycaemics insulin

5 Diabetes and Surgery Surgery is a form of physical trauma
It results in catabolism, increased metabolic rate, increased fat and protein breakdown, glucose intolerance and starvation. In a diabetic patient, the pre existing metabolic disturbances are exacerbated by surgery The type of diabetes, amount of insulin dose, diet or oral hypoglycaemic agents must be considered as this will change the overall management plan The risk of significant end-organ damage increases with the duration of diabetes, although the quality of glucose control is more important than the absolute time

6 Factors Adversely Affecting Diabetic Control Perioperatively
Anxiety Starvation Anaesthetic drugs Infection Metabolic response to trauma Diseases underlying need for surgery Other drugs e.g. steroids

7 Metabolic Responses to Surgery
Hormonal Secretion of stress hormones Cortisol Catecholamines Glucagon Growth Hormone Cytokines Relative decrease in insulin secretion Peripheral insulin resistance Metabolic Increased gluconeogenesis and glycogenolysis Hyperglycaemia Lipolysis Protein breakdown

8 Metabolic Response to Surgery and Diabetes
Hypoglycaemia May develop perioperatively due to the residual effects of preoperative long acting oral hypoglycaemic agents or insulin. Exacerbated by preoperative fast or insufficient glucose administration Counter-regulatory mechanisms may be defective because of autonomic dysfunction Can lead to irreversible neurological deficits Dangerous in anaesthetised or neuropathic patient as the warning signs may be absent Management Give i.v dextrose and monitor glucose levels

9 Metabolic Response to Surgery and Diabetes
Hyperglycaemia Glucagon, cortisol and adrenaline secretion as part of the neuroendocrine response to trauma, combined with iatrogenic insulin deficiency or glucose overadministration may result in hyperglycaemia Causes osmotic diuresis, making volume status difficult to determine and risking profound dehydration and organ hypoperfusion, and increased risk of UTI osmotic diuresis, delayed wound healing, exacerbation of brain, spinal cord and renal damage by ischaemia Results in hyperosmolality with hyperviscocity, thrombogenesis and cerebral oedema Management Frequently measure blood glucose and administer insulin

10 Metabolic Response to Surgery and Diabetes
Ketoacidosis Any patient who is in a severe catabolic state and has an insulin deficiency (absolute or relative) can decompensate into keto-acidosis Most common in type 1 patients Increased risk postoperatively, often precipitated by the stress response, infection, MI, failure to continue insulin therapy. characterised by hyperglycaemia, hyperosmolarity, dehydration (may lead to shock and hypotension) and excess ketone body production resulting in an anion gap metabolic acidosis.

11 Metabolic Response to Surgery and Diabetes
Management restore intravascular volume eliminate ketonaemia control blood glucose replace electrolytes monitor glucose and ketone levels Mortality from DKA –5-10% Electrolyte abnormalities Anticipate imbalances in potassium, magnesium and phosphate

12 Underlying Cardiac Complications of Diabetes and Surgery
Cardiovascular problems frequently present in long standing diabetics Ischaemic Heart Disease - Often silent ischaemia Coronary artery disease Hypertension Diabetic patients must be considered as being at high risk of MI Silent MI in autonomic neuropathy as Cardiac Autonomic Neuropathy may abolish the hearts response to stress Induction of anaesthesia and tracheal intubation can lead to a reduction in cardiac output

13 Underlying Cardiac Complications of Diabetes and Surgery
Management Most cardiac and antihypertensive drugs should be continued throughout the perioperative period except, aspirin, diuretics and anticoagulants History to determine effort tolerance, clinical examination for cardiac failure and an electrocardiogram in all patients. Echocardiography can help in assessing an ejection fraction in borderline cases

14 Underlying Renal Complications of Diabetes and Surgery
Renal dysfunction Intrinsic renal disease including glomerulosclerosis and renal papillary necrosis enhance the risk of acute renal failure perioperatively Proteinuria is an early manifestation Dialysis should optimally be done the day before surgery. Urinary infection Management Urea and electrolyte determination. Dipstix urinalysis for proteinuria

15 Underlying Nervous System Complications of Diabetes and Surgery
Counter-regulatory response to hypoglycaemia Peripheral glove and stocking neuropathy with an increased susceptibility to iatrogenic nerve injuries Cardiac Autonomic Neuropathy Management History of postural dizziness, post gustatory sweating, nocturnal diarrhoea and impotence. Careful documentation of peripheral sensation

16 Underlying Orthopaedic Complications of Diabetes and Surgery
Small Joint Disease Non-enzymatic glycosylation causing abnormal cross-linking of collagen may lead to joint rigidity At the atlanto-occipital joint, it may result in difficult intubation The small joints of the fingers and hands are also affected failure to approximate the palmar surfaces of the interphalangeal joints are indicators of a difficult laryngoscopy (positive prayer sign) Management Clinical assessment of neck extension, examination of the small joints of the hand and a good evaluation of the ease of intubation

17 Underlying Immune Complications of Diabetes and Surgery
Immune and infectious risk Diabetics are susceptible to infection and have delayed wound healing Hyperglycaemia facilitates proliferation of bacteria and fungi depresses the immune system management Proteolysis and decreased amino acid transport retards wound healing. Loss of phagocytic function increases the risks of post-operative infection Management Need very strict sterile techniques and need to assess risk/benefit ratio for procedures e.g catheterisation

18 Underlying Gastrointestinal and Opthamological Complications of Diabetes and Surgery
Gastroparesis Management History of early satiety and reflux H2 blocker and metoclopramide Ophthalmology Cataracts, glaucoma and retinopathy decrease visual acuity and increase the unpleasantness of the perioperative period Increase the amount of explanation and reassurance to the patient.

19 Principles of Managing Diabetics During Surgery
Management of preoperative insulin therapy depends on baseline blood glucose, level of diabetic control, severity of illness and the proposed surgical procedure However, aims for all diabetic patients are: No excess mortality No increase in post-op complications Normal wound healing No increase in duration of hospitalisation No hypoglycaemia, hyperglycaemia or ketoacidosis

20 Pre-operative Assessment
This is the most important step in the management of the diabetic patient Involves a thorough history and physical examination Review prior anaesthetic records to determine whether there were any difficulties with intubation or anaesthetics Lab investigations blood glucose - K+ BUN - creatinine ketones - proteinuria HbA1c (to assess how well controlled diabetes is)

21 Pre-Operative Management
Admit as early as possible prior to surgery Avoid long-acting glucose lowering agents chlorpropamide –glibenclamide ultralente insulins Avoid metformin Closely monitor blood glucose levels 2 hourly for Type 1 4 hourly for type 2 Test urine every 8 hours for ketones Place first on morning operating list if possible Aim for a blood glucose of 5-10mmol/L

22 Surgical Management of Insulin Dependant Diabetes Mellitus
Aim to keep blood glucose 5 to10mmol/L Pre operative NBM for 6 hrs prior to surgery (4 hrs for clear fluids) Anti aspiration prophylaxis Initiate glucose/ potassium/ insulin regime after commencing NBM (check K+ as well) 500ml 10% glucose solution with 20mmol K+ at connected to Y piece with insulin syringe Make up insulin syringe as 50 units insulin in 50 ml saline in a 50 ml syringe pump and run through Y piece with 10% glucose at between 1 to 5 u hr-1 (1 – 5 ml). Base on existing insulin regime Use sliding scale e.g. 1 u hr-1 if BG between 5 to 10 Hourly capillary glucose is measured until operation

23 Surgical Management of Insulin Dependant Diabetes Mellitus
Intra-operative Hourly glucose monitoring keep between 5-10 mmol/L Two hourly potassium monitoring keep between mmol/L Anaesthesia determined by patient physiology and surgical requirements Set up additional IV for resuscitation fluids

24 Surgical Management of Insulin Dependant Diabetes Mellitus
Post-operative Continue Glucose/Potassium/Insulin regime until patient can take orally Oral medication with first meal Allow for pain resulting in increased insulin requirements

25 Surgical Management of Non Insulin Dependant Diabetes Mellitus
Treat as insulin dependant if: poorly controlled (blood glucose >10 mmo/L) major surgery Pre-operative Biguanides must be stopped 48 hours before hand for fear of lactic acidosis NBM for 12 hours prior to operation Start i.v maintenance fluid 0.18% NaCl with glucose 4% Hourly capillary glucose is measured until operation

26 Surgical Management of Non Insulin Dependant Diabetes Mellitus
Hourly glucose monitoring Aim to keep within 5-10mmol/L if blood glucose >10 mmol/L, switch to treating as insulin dependant Post-operative Restart oral hypoglycaemics with first meal

27 Other Considerations with Anaesthesia in Diabetic Patients
Usual intra-operative monitoring record BP and pulse every 5 minutes watch skin colour and temp suspect hypoglycaemia if patient is cold and sweaty give IV glucose No contraindications to standard anaesthetic induction or inhalational agents If the patient is dehydrated then hypotension will occur and i.v. fluids will be needed

28 Conclusion The diabetic patient presents numerous challenges to management during surgery Awareness of the complications should enable tight metabolic control Correct management of the diabetic patient during surgery reduces morbidity and length of admission, as well as resulting in better wound healing

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