Care of Diabetic Patient During Surgery Hama Syria

Care of Diabetic Patient During Surgery Hama, Syria, 20/3/2019 By Dr. Jihad Khatib Endocrinologist

Care of Diabetic Patient During Surgery • The American Diabetes Association conservatively estimates that 12 -25% of hospitalized adult patients have diabetes mellitus (DM). • Approximately 25 -50% of all patients with diabetes will undergo surgery at least once in their lifetime • With the increasing prevalence of diabetic patients undergoing surgery, and the increased risk of complications associated with diabetes mellitus, • appropriate perioperative assessment and management are imperative. • 17% of all diabetes patients who undergo surgery will have some type of complications

Care of Diabetic Patient During Surgery • Mortality rates in diabetic patients have been estimated to be up to 5 times greater than in nondiabetic patients. • Diabetic Patients are more likely to develop cardiovascular complications than non- diabetics. • Diabetic Patients have a greater stress hormone response, and higher rate of perioperative complications and death than non – diabetics.

Risk of Surgery Associated with Diabetes • In the past, diabetes was considered to be a major cause of increased mortality during surgery (immediate postoperative mortality rate of 5%). • The main causes of mortality were myocardial infarction, ketoacidosis and infection.

• Infections account for 66% of postoperative complications and nearly one quarter of perioperative deaths in patients with DM. • Data suggest impaired leukocyte function, including altered chemotaxis and phagocytic activity. • Tight control of serum glucose is important to minimize infection.

Risk of Surgery Associated with Diabetes • Recent evidence suggest that, surgery is now safe for diabetic patients in terms of mortality and morbidity.

Why Surgery seriously interferes with normal diabetic control ?

Conditions Adversely Affecting Diabetic Control 1. Anxiety 2. Starvation 3. Anaesthetic Drugs 4. Infection 5. Metabolic response to trauma 6. Diseases underlying need for surgery 7. Other drugs e. g. . steroid

Risk of Surgery Associated with Diabetes I. Metabolic Responses to Surgery • • In normal subject the basic metabolic process of Anabolism and Catabolism are finely and exactly balanced. The key for the diabetic patient is the inability to increase insulin secretion to counteract the increases in the catabolic hormones.

Risk of Surgery Associated with Diabetes II. Surgical Trauma ACTH Cortisol Catecholamines, Glycogen, Growth hormone Aldosterone, Prolactine, Vasaopresine INSULIN (Insulin Resistance is commonly found )

Risk of Surgery Associated with Diabetes III. Associated conditions 1. Cardiovascular conditions 2. Diabetic Neuropathy 3. Musculoskeletal status 4. Diabetic Nephropathy 5. Respiratory conditions

Risk of Surgery Associated with Diabetes III. Associated conditions 1. Cardiovascular conditions • Long-standing diabetes is accompanied by hypertension and dyslipidemia with increase risk of ischemia, infarction and CVA. • Well-controlled hypertension does not pose a major risk to surgery, but patients receiving B-blockers may develop hypoglycemia without warning symptoms.

Risk of Surgery Associated with Diabetes III. Associated conditions 1. Cardiovascular conditions • Diabetes patients have increased thrombosis risks. • The use of vasopressors for treatment of severe hypotension may lead to remarkable peripheral vasoconstriction with risk of gangrene of the digits. • In diabetic autonomic neuropathy, there is loss of HRV, may be a contributory risk factor for ventricular arrhythmias and sudden death.

Risk of Surgery Associated with Diabetes III. Associated conditions 1. Cardiovascular conditions • Perioperative routine ECG recording is a mandate. • Loss of R–R variability when the heart rate at maximum inspiration is compared with the heart rate at maximum expiration implies the presence of Autonomic Cardiac Neuropathy.

Risk of Surgery Associated with Diabetes III. Associated conditions 2. Autonomic Neuropathy • Autonomic dysfunction, which is of particular importance to the anaesthetist, is detectable in up to 40% of type 1 and 17% of type 2 diabetic patients • In patients with autonomic neuropathy, insulin cause a decrease in arterial blood pressure and exacerbates postural hypotension.

Risk of Surgery Associated with Diabetes III. Associated conditions 2. Autonomic Neuropathy • Patients with peripheral neuropathy, have an increased susceptibility to peripheral nerve injury and soft tissue ischemia. • To prevent peripheral nerve compression and injury, pressure points must be carefully protected, pt. should be positioned carefully in the operating room and ICU.

Risk of Surgery Associated with Diabetes III. Associated conditions 2. Autonomic Neuropathy • Autonomic neuropathy may increase the risk of silent myocardial ischemia. • Hemodynamic instability may developed during sudden position changes or acute volume loss since the compensatory sympathetic responses may be lost.

Risk of Surgery Associated with Diabetes III. Associated conditions 2. Autonomic Neuropathy • Diabetic gastroparesis is characterized by a delay in gastric emptying without any gastric outlet obstruction and enhances the risk of acid aspiration. • Bladder dysfunction may lead to urinary retention, obstructive uropathy and fluid over load.

Risk of Surgery Associated with Diabetes III. Associated conditions 3. Musculo-Skeletal • The Stiff Joint Syndrome commonly seen with long-standing type I DM. • It’s manifestations include joint rigidity ( particularly air way support resulting in difficult intubation), short stature, and tight waxy skin.

Risk of Surgery Associated with Diabetes III. Associated conditions 3. Musculo-Skeletal Prayer Sign

Risk of Surgery Associated with Diabetes III. Associated conditions 4. Diabetic Nephropathy • Azotemic patients may have problems with fluid management, so CVP may be necessary. • Hyperkalemia with or without hyponatremia is often seen inpatient with mild to moderate renal insufficiency. • Proteinuria with hypoalbuminemia can cause extravasation of fluid to, increase intravascular volume , cardiac output and alveolar oxygen exchange.

Risk of Surgery Associated with Diabetes III. Associated conditions 5. Respiratory Dysfunction • Patients with long-standing type 1 diabetes and poor glycaemic control were found to have significantly decreased lung volume and lung diffusing capacity. • Post-operative respiratory arrest seems to common in diabetic patients. • Acute , unexpected respiratory problems in the recovery room are more common in men, in those aged > 60, and in obese diabetic patients.

Risk of Surgery Associated with Diabetes IV. Infection • Chronic Hyperglycemia has been associated with delayed wound healing due to inadequate collagen repair. • Poorly controlled diabetic patients have impaired leukocyte chemotaxis, defective immune defense mechanism, infections at surgical sites are common.

Aim of Treatment for Diabetics undergoing Surgery ü No excess mortality ü No increase post operative complications ü Normal wound healing ü No increase in hospital stay ü No hypoglycemia ü NO ketoacidosis or sever Hyperglycaemia

Preoperative Management of Diabetic Patient undergoing Surgery § Admit two days prior to surgery. § Arrange for surgery in the morning. § Make general medical assessment. § Closely monitor blood glucose levels.

Principles of Managing Diabetics During Surgery Non-Insulin dependant 1. Mild degrees surgery 2. Major operations Insulin therapy Insulin supplementation is needed is less essential

General Preoperative Management • In general, on the day of surgery, patients on oral regimens should be advised to discontinue these medications. • Secretagogues (eg, sulfonylureas, meglitinides) have the potential to cause hypoglycemia. In addition, sulfonylureas may interfere with ischemic myocardial preconditioning. • and may theoretically increase the risk of perioperative myocardial ischemia and infarction

Principles of Managing Diabetics During Surgery 1. Non Insulin Dependent • Ensure preoperative glycaemic control. • Omit oral hypoglycaemic on the morning. • Avoid glucose containing IV fluids. • Restart oral hypoglycaemic agents with first postoperative meal. • Monitor glucose levels every 2 hours initially.

• Patients who are insulin dependent are typically advised to reduce their bedtime dose of insulin the night before surgery to prevent hypoglycemia while nil per os (NPO).

For patients with type 1 DM: • it is recommended to schedule elective surgeries as the first case of the day to minimally disrupt their DM regimen. Depending on the length and extent of surgery. • patients may be advised to administer one half of their daily dose of long-acting insulin and to arrive at the preoperative admitting area early enough to have their serum glucose monitored and to determine whether they need intravenous dextrose until the time of surgery.

Principles of Managing Diabetics During Surgery Patients on insulin should considered to be Insulin Dependent Management must include Insulin & Glucose for all grades of surgery

Principles of Managing Diabetics during Surgery 2. Insulin Dependent • Many advocate perioperative insulin infusion (along with potassium and dextrose) as a routine management of insulin dependent patients undergoing major surgery. • A reasonable intra-operative goal is to keep the glucose level between 140 - 170 mg/dl

Principles of Managing Diabetics During Surgery I. GIK Regime G 10% (100 ml/h) + 10 m mol K cl 117 mg/dl 117 -197 mg/dl 10 U 15 U 20 U insulin

GIK Regime * Test strip / 2 hrs * K level 4 -6 hrs post operative. * Urea, Creatinine & electrolyte next day

Principles of Managing Diabetics During Surgery II. Insulin-Glucose infusion Blood Glucose Infusion mg / dl =<70 71 -100 101 -150 151 -200 201 -250 251 -300 >300 Insulin Infusion units/h 0. 5 1. 0 1. 5 2. 0 3. 0 4. 0 6. 0 1 - Blood glucose level every 1 h interval 2 -Insulin infusion with 0. 5 units/ml saline 3 - Keep blood glucose level between 100 and 120 mg/dl 4 - Should not be stopped until 1 -2 h after sc insulin D 5 W ml / h 150 125 100 75 50 0 0

Principles of Managing Diabetics Postoperative Blood Glucose mg/dl >70 71 -100 101 -150 151 -200 201 -250 251 -300 >350 Short Acting Insulin ( units ) Breakfast 3 4 6 8 10 12 14 Lunch 2 3 4 6 8 10 12 Dinner 10: 00 p. m. 2 3 4 6 8 10 12 1 - Blood glucose before meals, at 10 pm. , and at 3: 00 a. m. 2 -Provide 3 meals and 3 snacks (20 -30 kcal /kg /day ) 3 -Administer long-acting insulin 10 -20 u sc at 10 p. m. 4 -Blood glucose at 3: 00 am to reduce the 10: 00 pm insulin dose 0 0 1 2 3

• An elevated Hb. A 1 c immediately before surgery may provide insight to a patient’s risk for postoperative diabeticrelated complication