1. Diabetes and surgery

2. Diabetes mellitus (DM), also known as simply diabetes, is a group of metabolic diseases in which there are high blood sugar levels over a prolonged periodblood sugar

3. any one of the following- Fasting plasma glucose level ≥ 7.0 mmol/l (126 mg/dl) Plasma glucose ≥ 11.1 mmol/l (200 mg/dl) two hours after a 75 g oral glucose load as in a glucose tolerance test Plasma glucose glucose tolerance test Symptoms of hyperglycemia and casual plasma glucose ≥ 11.1 mmol/l (200 mg/dl) Glycated hemoglobin (Hb A1C) ≥ 6.5%. Glycated hemoglobin

4. Serious long-term complications include heart disease, heart disease stroke, stroke kidney failure, kidney failure foot ulcers and foot ulcers damage to the eyes. damage to the eyes

5. Type 1 DM results from the body's failure to produce enough insulin. This form was previously referred to as "insulin-dependent diabetes mellitus" (IDDM) or "juvenile diabetes". The cause is unknown. Type 1 DM

6. Type 2 DM begins with insulin resistance, a condition in which cells fail to respond to insulin properly. As the disease progresses a lack of insulin may also develop. This form was previously referred to as "non insulin- dependent diabetes mellitus" (NIDDM) or "adult-onset diabetes". The primary cause is excessive body weight and not enough exercise. Type 2 DMinsulin resistance

7. Gestational diabetes, is the third main form and occurs when pregnant women without a previous history of diabetes develop a high blood glucose level.Gestational diabetes Type 1 diabetes must be managed with insulin injections.insulin Type 2 diabetes may be treated with medications with or without insulin.

8. Surgical complications of Diabetes are due to 1) Micro vascular changes involving the capillaries of retina, kidneys, and peripheral nerves. 2) Macro vascular changes characterized by atherosclerotic lesions of the coronary and peripheral arterial circulation. 3) Diabetic neuropathy. 4) Infection in glucose loaded tissue.

9. Surgical complications in Diabetic Patient Bacterial infections like abscesses, carbuncles, chronic balanitis, and diabetic foot. Emphysematous Cholecystitis, Emphysematous Pyelonephritis, Necrotising fasciitis and Fournier’s gangrene Fungal infections like candidiasis, Mucormycosis. Sexual dysfunctions

11. Diabetic foot Most feared and devastating complication of diabetes Most common cause for leg amputations The classic pathological triad of the diabetic foot is vascular disease, neuropathy and infection

12. Wagner’s classification for diabetic foot Grade 0 : High risk foot. No ulceration Grade 1 : Superficial ulceration Grade 2 : Deep ulceration penetrating up to tendon, bone or joint Grade 3 : Osteomyelitis or deep abscess Grade 4 : Localized gangrene (Toes or fore foot) Grade 5 : Extensive gangrene (mid foot or hind foot) requiring major amputation

14. Neuropathic foot Sensory, autonomic and motor neuropathy contribute to the pathogenesis of Neuropathic foot. Motor weakness leads to atrophy of the small muscles of the foot with an imbalance between the flexors and extensors. This results in clawing of the toes and prominent metatarsal heads. High foot pressure develops under the metatarsal heads. Dry, brittle skin (as a result of autonomic neuropathy) and high foot pressure lead to callus formation. The callus can cause tissue damage and ulceration.

15. Diagnosis and assessment of diabetic foot Thorough neurological examination to detect sensory, motor or autonomic nerve deficit. H/o rest pain, intermittent claudication. Examination of peripheral pulses, capillary filling. Doppler study. Estimation of blood glucose, Hb.TLC,DLC, urea, creatinine and lipids. X ‐ ray to detect osteomyelitis

16. Management of diabetic foot Infections are treated by wound debridement, proper antibiotic, multiple insulin injections to achieve good control of blood glucose. Exercise, cessation of smoking. Use drugs like pentoxyphylline, aspirin, and thrombolytic agents to improve blood supply. Angioplasty, bypass, stenting, atherectomy and laser ablation of atherosclrotic plaque

17. Attempt to convert wet gangrene to a dry one by repeated dressings and proper antibiotics. Once gangrene sets in, decide for amputation.

18. Surgery in diabetic patients Diabetic patients are prone to develop sudden hyperglycemia or hypoglycemia during surgery. So, frequent monitoring of blood glucose is necessary. Short acting insulin is given during surgery and in the immediate postoperative period. They are admitted a few days ahead of surgery.

19. Oral hypoglycemic drugs are stopped a few days before major surgery and insulin is started, to bring about better control of blood sugar. Insulin is continued for a few days in the postoperative period also. Wound healing is likely to be delayed

20. Q1-Dibetes mellitus is defined when in glucose tolerence test ( 75 g glucose followed by blood sugar measurement, after 2 hr) is A. less than 140 mg/dl B. between 140-200 C. >200 mg/dl D.180 mg /dl

21. 2.Long term complication of DM is- a.Heart disease b. renal disease c. diabetic foot d. all above

22. 3.Most common cause for leg amputation- a.venous ulcer b.trauma c.Buerger disease d. diabetic foot

23. 4.Grade 3 diabetic foot ( wager classification)- a.superficial ulcer b.deep ulcer exposing bone, joint,tendon c.osteomyelitis d. gangrene

24. 5. A diabetic pt on oral hypoglycemic agent is planned for surgery, which one is true- a. oral hypoglycemic drug should not be stopped b.oral hypoglycemic agent should be stopped few days before surgery and long acting insulin should be started pre and post op c.oral hypoglycemic agent should be stopped few days before surgery and short acting insulin should be started pre and post op for few days

25. 6. In diabetic patient level of Glycated haemoglobin (HB A1C) is more than A.8.0% b.6.5% c.4.5% d. 9.2%