perioperative diabetes mellitus management

1. PERIOPERATIVE MANAGEMENT
OF DIABETES MELLITUS
SPEAKER
Dr. DHARMRAJ SINGH
MODERATOR
Dr. SHASHI PRAKASH

2. INTRODUCTION
 Patients with diabetes have higher incidence of morbidity and
mortality.
 Poor peri-operative glycaemic control increases the risk of adverse
outcomes.
 Treatment of post-operative hyperglycaemia reduces the risk of
adverse outcomes.

3. CRITERIA FOR DIAGNOSIS OF
DIABETES
1. Symtoms of diabetes plus random plasma glucose level >200 mg/dL
(11.1 mmol/L)
2. Hemoglobin A1C ≥ 6.5 %
3. Fasting plasma glucose level ≥ 126 mg/dL (7.0 mmol/L)
4. Two-hour plasma glucose level ≥ 200 mg/dL (11.1 mmol/L)
American Diabetes Association

4. METABOLIC SYNDROME
At least three of the following
 Fasting plasma glucose ≥ 110 mg/dl
 Abdominal obesity (waist girth > 40 [in men], 35 [in women])
 Serum triglycerides ≥ 150mg/dl
 Serum HDL cholesterol < 40 mg/dl (men), <50 (women)
 BP ≥ 130/85 mm Hg
 Insulin-resistant syndrome is a constellation of clinical & biochemical
characteristics frequently seen in pt with or at risk of type 2 diabetes.

5. THE METABOLIC RESPONSE TO SURGERY
AND THE EFFECT OF DIABETES
Metabolic effects of starvation:
1. Period of starvation induces a catabolic state.
2. It will stimulate secretion of counter-regulatory hormones .
3. It can be attenuated in patients with diabetes by infusion of insulin and
glucose (approximately 180g/day).
Metabolic effects of major surgery.
It causes neuroendocrine stress response with release of counter- regulatory
hormones (epinephrine, glucagon, cortisol and growth hormone) and of
inflammatory cytokines IL-6 and tumor necrosis factor-alpha.

6. CONTD…
Hypoglycaemia – exacerbate the catabolic effect of surgery
These neuro hormonal changes result in metabolic
abnormalities including
 Increased insulin resistance.
 decreased peripheral glucose utilization.
 impaired insulin secretion.
 increased lipolysis .
 protein catabolism, leading to
hyperglycemia and even ketosis in some cases…

7. WHY SPECIAL CONCERNS ?
 Hypo and hyperglycemia.
 Multiple co-morbidities including microvascular
and macrovascular complications.
 Complex polypharmacy , including misuse of Insulin.
 Inappropriate use of intravenous insulin infusion.
 Management errors when converting from the
intravenous insulin infusion to usual medication.
 Peri-operative infection.

8. PRE-OPERATIVE EVALUATION
 Determine the type of diabetes and its management.
 Ensure that the patient’s diabetes is well controlled.
 Review of medications.
 Ensure that the patient is capable of managing their diabetes after
discharge from hospital.
 Consider the presence of complications of diabetes that might be
adversely affected by or that might adversely impact upon the outcome
of the proposed procedure.
 Identify high-risk patients requiring critical care
management.

9. PRE-0PERATIVE EVALUATION
To Assess History/Examination Investigation
1.Blood Sugar Control
Hypo/Hyperglycemic
episodes,
Hospitalization,
Medical compliance
BS- F & PP
HbA1C
2. Nephropathy H/O- HTN, Swelling over body,
Recurrent
UTI.
Urine R/M (to exclude
Albuminuria and UTI)
RFT
3.Cardiac Status H/O- Angina/ MI , Swelling of
feet,
Exercise intolerance
ECG, CXR, ECHO,TMT
(ECG-less predictive )
4. PVD H/O- Intermittent Claudication,
Blanching of feet,
Non healing ulcer

10. CONTD..
To Assess History/Examination Investigation
5. Retinopathy H/O-Visual disturbances
↑ power of lenses
Fundus Examination
6. ANS
Early satiety, abdominal
distension, Anhidrosis, Impotence,
Orthostatic Syncope
Postural change in BP, HR
variability with exercise,
tachycardia response to
atropine
7. Metabolic &
Electrolyte
H/O- Starvation, Infection
Sign of DKA,
ABG, Urinary Ketone,
Sr. Electrolyte
8. Airway Scleroderma of Diabetes
Stiff Joint Syndrome
(Prayer sign, Palm Print test)
X-ray cervical spine
AP & Lateral

11. CONTD….
Prayer Sign:
Patient is unable to approximate
the palmar surface of phalangeal
joints despite of maximal effort.
Palm Print Test:
Degree of inter-phalyngeal joint
involvement can also be assessed
by scoring the ink impression
made by the palm of dominant
hand.

12. CLINICAL SIGNS OF DIABETIC
AUTONOMIC NEUROPATHY
 Hypertension
 Painless MI
 Orthostatic hypotension
 Lack of HR variability
 Reduced HR response to atropine & propanolol
 Resting tachycardia
 Early satiety
 Nerugenic bladder
 Lack of sweating
 Impotence

13. TESTS FOR DIABETIC AUTONOMIC
NEUROPATHY (DAN)
 Early stage: abnormality of HR response during deep breathing
 Intermediate stage: abnormality of Valsalva response
 Late stage: presence of postural hypotension
 The test are valid marker of DAN if following factors ruled out.
1. End organ failure
2. Concomitant illness
3. Drungs: antidepressents, antihistamines, diuretics, vasodilators,
sympathatic blockers, vagolytics.

14. TEST FOR AUTONOMIC
NEUROPATHY
Heart rate variability (HRV) in response to:
Deep breathing
Standing
Valsalva maneuver
BP response to:
1.Standing or passive tilting
2.Sustained hand grip
3.Valsalva maneuver

15. GENERAL PRINCIPLES
Diabetes should be well controlled prior to elective surgery.
Avoid insulin deficiency, and anticipate increased insulin
requirements.
The patient’s diabetes care provider should be involved in
the management of their patient’s diabetes peri-operatively.
Patients must be given clear written instructions concerning the
management of their diabetes both pre- and post-operatively
(including medication adjustments) prior to surgery.

16. CONTD…
 Patients must not drive themselves to the hospital on the day of
the procedure.
 Patients with diabetes should be on the morning list, preferably
first on the list.
 These guidelines may need to be individually modified
depending on the patient’s circumstance.
 Patients should be well hydrated before the procedure.

17. GOALS
To maintain glycaemic control.
To prevent further deterioration of pre-existing end organ damage
and minimise the metabolic consequence of starvation and surgical
stress.
To shift patient soon on pre-operative glycaemic control drugs and
prevention of PONV.
To prevent complication.
Greater concern for aseptic precaution.
Postoperative pain management.

18. GLYCEMIC CONTROL
 Postpone elective surgery if possible if glycaemic control is poor
(HbA1c ≥ 9%).
 For major surgery, if serum glucose is >270 mg/dl preoperatively,
surgery should be delayed while rapid control is achieved with IV
insulin.
 If serum glucose is >400 mg/dl , the surgery should pe postponed and
metabolic state restabilized.

19. CONTD…
 BGL should be kept between 5 – 10mmol/l (90-180mg/dl) during the
perioperative period .
 For critically ill patients who require admission to the intensive care
unit post-operatively, a “tighter” BGL target (e.g 4.4-6.1 mmol/L) may
not convey any greater benefit.
 Hypoglycemia must be avoided.
 All patients with diabetes treated with insulin should be managed in
the same way, irrespective of whether they have type 1 or type 2 diabetes
mellitus.

20. CONTD…
 Insulin management dependent on
Pre-op glycemic control
Insulin regimen
Magnitude of surgery
Timing and duration of surgery
Resumption of patients usual diet.
 Minor surgery is defined as all day-only procedures,
while major surgery includes all procedures that require at
least an overnight admission*
PERIOPERATIVE DIABETES MANAGEMENT GUIDELINES-AUSTRALIAN DIABETES SOCIETY MAY 2011

21. PATIENTS WHO REQUIRE INSULIN THERAPY
This group includes patients with type 1 diabetes or patients with type 2 diabetes
who require day time insulin injections.
Patients who take both evening and morning doses of insulin should take their
usual dose of evening short-acting insulin, but reduce their intermediate- or long-acting
dose by 20% the night before surgery.
On the morning of surgery, they should omit their short-acting insulin and reduce
the intermediate- or long-acting dose by 50% (and take this only if the fasting
glucose is >120 mg/dl)
Premixed insulin → reduce their evening dose prior surgery by 20% and hold
insulin completely on the morning of procedure.
Some patients receiving insulin may also take oral AHG.

22. MAJOR SURGERY(MORNING LIST)
Maintain the usual insulin doses and diet the day before, and fast from
midnight.
 Omit usual morning insulin (and AHG).
 Commence an insulin-glucose infusion prior to induction of
anaesthesia (or by 1000hrs at the latest).
 Measure BGL at least hourly during the intra-operative period.
 Continue the insulin-glucose infusion for at least 24 hours post-operatively
and until the patient is capable of resuming an adequate oral
intake
*PERIOPERATIVE DIABETES MANAGEMENT GUIDELINES-AUSTRALIAN DIABETES SOCIETY MAY 2012

23. MAJOR SURGERY(AFTERNOON LIST)
 Give a reduced dose of insulin before early breakfast in the morning.
(reduced bolus insulin plus 1/2 day time dose as intermediate/long acting
insulin)
 Patients should arrive at the facility by 0900hrs and BGLs should be
monitored closely in the pre-operative ward.
 Commence an insulin-glucose infusion before induction of anaesthesia.
*PERIOPERATIVE DIABETES MANAGEMENT GUIDELINES-AUSTRALIAN DIABETES SOCIETY MAY 2012

24. MINOR SURGERY
MORNING
LIST
 Delay the usual morning dose of insulin
provided that the procedure is completed
and the patient is ready to eat by 1000hrs.
The patient can then have a late breakfast
after
the usual dose of insulin is given.
 For later procedures, give a reduced
dose of insulin in the morning in the
form of
intermediate or long-acting insulin if
possible.
 If the BGL remains elevated (>10mmol/l),
an I-G infusion should be commenced.
AFTERNOON
LIST
 Pre-operative insulin adjustments similar
to that for major surgery in the afternoon.
 An insulin-glucose infusion may be
necessary if pre-operative insulin
adjustments result
in hyperglycemia.
 Overnight admission may be
necessary for those with glycemic
instability or who are
unable to resume their usual diet before
discharge

25. PATIENTS ON ORAL AHG MEDICATION
(WITHOUT INSULIN)
 Stop AHG medication on the day of surgery.
 Restart AHG medication when patients are able to resume normal
meals (except possibly metformin and thiazolidinediones following
cardiac surgery).
 Commence an I-G infusion if the BGL >10 mmol/L(180mg/dl); if
surgery is prolonged and complicated; or if the patient is usually
treated with more than one oral AHG agent.
 Subcutaneous insulin may be required post-operatively
*PERIOPERATIVE DIABETES MANAGEMENT GUIDELINES-AUSTRALIAN DIABETES SOCIETY MAY 2012

26. PATIENTS ON DIET ALONE
For patients whose diabetes is maintained on diet alone and who
are well controlled (HbA1c < 6.5%), no specific therapy is required,
but more frequent BGL monitoring during the peri-operative period is
recommended. During the procedure, BGLs should be checked hourly.
BGL remains above 10 mmol/L (180mg/dl) in the pre- or peri-operative
period, an I-G infusion should be commenced and continued until
they resume eating.
 If the patient does not become hyperglycemic following surgery, the
patients BGL ‟ should be monitored every 4 – 6 hours until they
resume their usual meals.
Patients who are hyperglycemic peri- or post-operatively may require
supplemental insulin and/or the initiation of specific AHG
*PERIOPERATIVE DIABETES MANAGEMENT GUIDELINES-AUSTRALIAN DIABETES SOCIETY MAY 2012

27. THE POST-OPERATIVE PERIOD
 Insulin-glucose infusions should be continued until the patients can resume
an adequate diet.(or atleast 24 hrs)
 I-G infusions should ideally be stopped after breakfast, and a dose of
subcutaneous insulin (or oral AHG) is given before breakfast.
 Hyperglycemia detected post-operatively in patients not previously known
to have diabetes should be managed as if diabetes was present, and the
diagnosis of diabetes reconsidered once the patient has recovered from their
surgery.
 Diabetes medication requirements may be increased (or occasionally
decreased) in the post-operative period, and frequent BGL monitoring is
therefore essential.
 Diabetes management expertise must be available for the post-operative
management of glycemic instability.

28. SLIDING SCALE REGIMEN
S/C
Glucose in mg/dl Regular Insulin S/C
150-200 2 unit
201-250 4 unit
251-300 6 unit
301-350 8 unit
≥350 10 unit

29. ALBERTI’S OR GKI REGIMEN
 Blood sugar to be stabilised 2-3 days prior to surgery
 Start GKI infusion @ 100-125 ml/ hr
Blood Sugar in mg/dl
Infusion
(10%dextrose+insulin+K+)
≤90 10+5+10
90-180 10+10+10
180-360 10+15+10
≥360 10+20+10

30. TIGHT CONTROL REGIMEN
 Target Blood Sugar is 80-110 mg/dl.
 Indications: Pregnancy, CPB, Neurosurgery.
 Advantages: Improve wound Healing,
Prevent wound infection,
Improve neurological outcome.
 Night before surgery do preprandial glucose.
 Start 5% Dextrose @ 50 ml/hr.
 Dissolve 50 U of insulin in 250 ml of NS and start piggy back
infusion.
 Insulin infusion rate is adjusted by BG/150 U per hr and
BG/100 U per hr if pt is obese or on steroid or in sepsis.
RISK – HYPOGLYCEMIA

31. ARRANGEMENT OF INTRAVENOUS LINE FOR
INFUSION OF REGULAR INSULIN

32. VELLORE REGIMEN
 All patients had blood glucose measured at 6 am.
 For those patients whose operation started in the morning (7:30 am), no
glucose or insulin was given in the ward.
 All other patients receive a glucose insulin infusion in the ward, if their blood
glucose is more than 100 mg/dL.
 Regular insulin 5 U in 500 mL of 5% dextrose in water solution (D5W) was
started in the ward at 8 am @ 100 mL/hr until the time of operation.

33. VELLORE REGIMEN
Blood sugar (mg/dL) Treatment
<70 Stop insulin if on insulin. Rapid infusion of 100 mL of
D5W, measure blood glucose after 15 min
71-100 Stop insulin, infuse D5W at 100mL/h
101-150 1U of insulin + 100 mL of D5W/h
151-200 2U of insulin + 100 mL of D5W/h
201-250 3U of insulin + 100 mL of D5W/h
251-300 4U of insulin + 100 mL of D5W/h
>300 1U of insulin for every 1-50 mg more than 100 mg/dL +
100 ml of normal saline/h

34. VIARIABLE RATE INTRAVENOUS
INSULIN INFUSION(VRIII)
 Make up a 50 ml syringe with 50 units of soluble human insulin in
49.5mls of 0.9% sodium chloridesolution. This makes the concentration
of insulin 1 unit per ml.
 The substrate solution to be used alongside the VRIII should be selected
from:
• 0.45% saline with 5% glucose and 0.15% KCl, or
• 0.45% saline with 5% glucose and 0.3% KCl
 The rate of fluid replacement must be set to deliver the hourly fluid
requirements of the Individual.( volumetric infusion pump).
 Delivery of the substrate solution and the VRIII must be via a single
cannula with appropriate one-way and anti-siphon valves .

35. RATE OF INSULIN INFUSION
Bedside capillary glucose (mmol/L) Initial rate of insulin infusion
(units/hour)
<4.0 0.5
(0.0 if a long acting background insulin
has been continued )
4.1-7.0 1
7.1-9.0 2
9.1-11.0 3
11.1-14.0 4
14.1-17.0 5
17.1-20 6
>20 Seek diabetes term of medical advice

36. FLUID MANAGEMENT
Aims of fluid management:
• Provide glucose as substrate to prevent proteolysis, lipolysis and
ketogenesis.
• Maintain blood glucose level between 6-10mmol/L where possible
(acceptable range 4-12mmol/L).
• Optimise intravascular volume status.
• Maintain serum electrolytes within the normal
ranges.

37. CONTD…
The daily requirement of the healthy adult is :
• 1.5-2.5 litres of water
• 50-100 mmol of sodium,
• 40-80 mmol of potassium,
• 180g glucose is needed to prevent catabolism(particularly DM).
• Diabetic patients may require magnesium, phosphate…..

38. FLUID MANAGEMENT FOR PATIENTS
REQUIRING A VARIABLE RATE
INTRAVENOUS INSULIN INFUSION*
 The substrate solution to be used alongside the VRIII should be based on
serum electrolytes,measured daily and selected from:
 0.45% saline with 5% glucose and 0.15% potassium chloride (KCl) OR
0.45% saline with 5% glucose and 0.3% KCl.
* Management of adults with diabetes undergoing surgery and elective procedures: improving
standards- NHS(National institute for health and clinical excellence ) APRIL 2011

39. CONTD…
 Very occasionally, the patient may develop hyponatremia
without signs of fluid or salt overload, In such cases 0.45%
saline is replaced by 0.9% saline with dextrose and
potassium.
 hypovolemia/hypotension – treat with crystalloids.
• 0.9% Normal saline
• Hartman solution(Gluconeogenic since lactate/acetate) not
contraindicated in diabetic(Interfere with glycemic control )
•1) Management of adults with diabetes undergoing surgery and elective procedures: improving standards- NHS(National institute for health
and clinical excellence ) APRIL 2011.
•2) Guidelines for intravenous fluid therapy for adult surgical patients(GIFTASUP )MAR 2011.

40. FLUID MANAGEMENT FOR PATIENTS NOT
REQUIRING A VARIABLE RATE
INTRAVENOUS INSULIN INFUSION
 Aims of fluid management:
• Provide intravenous fluid as required according to individual need until the
patient has recommenced oral intake
• Maintain serum electrolytes within the normal ranges
• Avoid hyperchloraemic metabolic acidosis.
 Recommendations *
• Hartmann’s solution should be used in preference to 0.9% saline.
• Glucose containing solutions should be avoided unless the blood glucose is
low.
•1) Management of adults with diabetes undergoing surgery and elective procedures: improving standards- NHS(National institute for
health and clinical excellence ) APRIL 2011.
•2) Guidelines for intravenous fluid therapy for adult surgical patients(GIFTASUP)MAR 2011.

41. ANAESTHESIA AND DIABETES

42. PREOP FASTING
 Atleast 6 hrs for solid foods.
 Patients with gastroparesis , 12 hrs may be needed. Such
patients are given H2 receptor blocker(Ranitidine) and
prokinetics (metoclopromide).
 When fasting exceeds 8-10 hrs then insulin-glucose infusion
has to be started to prevent catabolism.
Gastric emptying
(1)- in DM patients
(2)- after Metoclopromide
(3)- normal person

43. CONCERNS…
 DM affects oxygen transport by causing glucose binding to Hb.
 DM is considered CAD equivalent.
 Chronic kidney disease is asymptomatic in diabetic and usually advanced.
 Autonomic dysfunction :
• Exagerated Hypotension
• Risk of hypothermia
• Sympathetic response are blunted
• Silent MI

44. CONTD…
 Inhibits intestinal motility, delayed gastric emtying.
 Difficult Airway-
• restricted joint movement(atlanto-occipital)
• obesity
 Therapy related-
• Sulphonylureas - hypoglycemia
• Metformin - lactic acidosis
• Incretins & amylin - delays gastric emptyig , nausea

45. PHARMACOLOGY
 Propofol – lipid loading lead to impaired metobolism in DM, decreased lipid
clearance. Its of more concern when given in infusion.
 Etomidate -  decreases adrenal steroidogenesis  decreased glycaemic
response to surgery.
Ketamine- may cause significant hyperglycemia
Midazolam –(high doses/infusion)
 decreases ACTH & Cortisol  decreased sympathoadrenal
stimulation  decreased glycemic response to surgery.
Alpha-2 adrenergic agonist – decreases sympathetic outflow from
hypothalamus, decreases ACTH. improves glycemic control.

46. CONTD…

47. REGIONAL ANAESTHESIA
ADVANTAGES
Regional anaesthesia blunts the
increases in catecholamines
,cortisol, glucagon, and glucose.
Metabolic effects of anaesthetic
agents avoided
An awake patient – hypoglycaemia
readily detectable.
Decreased chance of Aspiration,
PONV and Thromboembolism.
Rapid return to diet and Sc
insulin/OHA
DISADVANTAGES
If autonomic neuropathy is
present, profound hypotension
may occur.
Infections and vascular
complications may be
increased (epidural abscesses
are more common in diabetics)
 Medicolegal concern of risk of
nerve injuries and higher risk
of ischaemic injury due to use
of adrenaline with LA

48. GENERAL ANAESTHESIA
ADVANTAGES
• High dose opiate technique may be
useful to block the entire
sympathetic nervous system and
the hypothalamic pituitary axis.
• Better control of blood pressure in
patients with autonomic
neuropathy.
DISADVANTAGES
May have difficult airway. (“Stiff-joint
syndrome”)
Full stomach due to gastroparesis.
Controlled ventilation is needed as
patients with autonomic neuropathy may
have impaired ventilatory control.
Aggravated haemodynamic response to
intubation.
It may masks the symptoms of
hypoglycaemia

49. ANAESTHESIA & DM
SPECIAL SITUATIONS

50. PREGNANCY
 Pregnancy is a diabetogenic state. As pregnancy advances insulin resistance
increases.
 Hyperglycemia during pregnancy has both maternal and fetal complications
& adverse outcome.
 Challenges – Altered maternal physiology & disease associated with
pregnancy.
Maternal hyperglycaemia :
 Increases the risk of neonatal jaundice.
 The risk of neonatal brain damage, and
 Fetal acidosis if the fetus becomes hypoxic

51. GDM-DIAGNOSIS
ADA-American diabetes association guidelines 2011

52. CONCERNS…
 Need tighter control.
• Premeal- 60-90mg/dl.
1 hr pp - < 140mg/dl.
2 hr pp - < 120mg/dl.
 More prone for hypoglycemia /hyperglycemia
 DKA – usually occurs during 2nd/ 3rd trimester, even develops
with low glucose value of 200mg/dl.

53. DIABETIC CRISIS
 HYPERGLYCEMIC :
• DKA
• HYPEROSMOLAR NONKETOTIC COMA.
 HYPOGLYCEMIC:

54. DKA
BG≥ 250 mg/dl
Acidosis-pH<7.3
Serum HCO3<15meq/l
Serum Ketone>7meq/l
Osmolarity-300-320
K+ ↑/ ↓
Urine may be positive for
ketone body.
↑ anion gap metabolic acidosis
↑ serum amylase
EM

55. LAB VALUES IN DKA & HHS
DKA HHS
Glucose mmol/l (mg/dl) 13.9-33.3 (250-600) 33.3-66.6 (600-1200)
Na meq/l 125-135 135-145
K meq/l N to ↑ N
Mg N N
Cl N N
PO4 N to ↓ N
Creatinine μmol/l (mg/dl) Slightly ↑ Moderately ↑
Osmolarity (mOsm/ml) 300-320 330-380
Plasma ketones ++++ ±
Serum HCOӡ meq/l <15 meq/l N to slightly ↓
Arterial pH 6.8-7.3 >7.3
Arterial PCO2 mmHg 20-30 N
Anion gap meq/l ↑ N to slightly ↑

56. DKA - MANAGEMENT
Insulin replacement-
0.1U/kg bolus followed by 0.1U/kg/hr and if BG does not ↓ by 10%-repeat
the loading dose –if still no response –double the infusion dose in every
2 hr.
Fluids:
0.9% NS-1-2 ltr in 1st hr
0.45%NS-2-5 ml/kg/hr
0.45%NS - when the BG< 250 mg/dl
& 5%DS
Electrolyte:
20-30meq of K+/ hr after 2 hr of t/t
Replace phosphate when, <1mg/dl

57. HNKC- MANAGEMENT
Insulin replacement:
Less insulin require as compared to DKA 15 U i.v bolus then 0.1 U/kg/
hr
Fluids: Reqirement is more than DKA
0.9% NS-2-3 ltr in 2-3 hr
0.45%NS-2-5 ml/kg/hr
0.45%NS - when the BG< 250 mg/dl
& 5%DS
Electrolyte:
20-30meq of K+/ hr concurrently

58. HYPOGLYCEMIA
 Blood sugar < 50 mg/dl.
 Symptoms due to Adrenergic excess and Neuroglycopenia.
 Sweating, tachycardia/bradycardia , tremers, hypotension,
dizziness, irritability, seizures, or coma.
 Stop insulin & give dextrose 20-30 ml 50%dxtrose
 Dextrose infusion
 Glucagon (0.5-1.0 mg IM )
 Octreotide(sulphonylurea)

59. DM & EMERGENCY SURGERY
Usually Infected
Usually Uncontrolled
Dehydrated
Metabolic decompensated
Increased resistance to insulin
More Chances of acute Hyperglycemic complication

60. EMERGENCY SURGERY
 Little time for stabilisation of patients ,but if 2-3 hr available
• correction of fluid and electrolyte imbalance .
• Correct hyperglycemia.(start I-G infusion if sugar > 180mg/dl)*
• Treat acidosis.
• Avoid hypoglycemia.
 Surgery should not be delayed in an attempt to eliminate
ketoacidosis completely if the underlying condition will lead to
further metabolic deterioration.
* Management of adults with diabetes undergoing surgery and elective procedures: improving standards-
NHS(National institute for health and clinical excellence ) APRIL 2011

61. CONTD…
 If enough time is not available – correction of hydration status ,
electrolytes, acidosis, blood sugar should be started & should
achieve an improving metabolic trend before starting
anaesthesia.
Likelyhood of intra-op hypotension and arrhythmia is more
particularly if pt has pre-op acidosis or hypokalemia.
Intra-op sugar to be monitored more frequently.
 Atleast hourly.
 LSCS – every 30 min.*
* Management of adults with diabetes undergoing surgery and elective procedures: improving standards-
NHS(National institute for health and clinical excellence ) APRIL 2011

62. CHILDREN & ADOLESCENSE
WITH DM
 Diagnostic criteria same as adults.*
 Minimise physiological & metabolic stress.
 Maintain Euglycemia.
 Hyperglycemia reflects the dehydration/hypovolemia,and not the adequacy
of insulin therapy.
 Sr.glucose > 300mg/dl, hyperglycemia inversely proportional to renal
function.(higher the glucose lower the creatinine clearance) .

63. CONTD…
 The magnitude of hyperglycemia proportional to the
magnitude of dehydration.
 So, only Rehydration decreases the blood sugar & not insulin.
 So ,the insulin dose is determined by the magnitude of
metabolic stress and acid-base status.

64. CONTD…
 Aim for blood glucose levels between 5-10 mmol/l (90-180 mg/dl) during
surgical procedures in children.
 No solid food for at least 6 hours prior to surgery.
 To minimise the risk of hypoglycaemia, children should receive a glucose
infusion when fasting for more than 2 hours before a general anaesthesia.
 At least 2 hours before surgery start an IV insulin infusion.
ISPAD-Management of childhood& adoloscence diabetes guidelines 2011

65. CONTD…
 Monitor blood glucose hourly before surgery and every 30-
60 minutes during the operation and until the child recovers
from anaesthesia. Adjust IV insulin accordingly.
 Do not stop the insulin infusion if BG <5–6 mmol/l (90 mg/dl)
as this will cause rebound hyperglycemia. Reduce the rate of
infusion.

66. MAINTENANCE FLUID GUIDE:
Glucose:
5 % glucose; 10 % if there is concern about hypoglycaemia. If BG is high
(>14 mmol/l, 250 mg/dl), normal saline without glucose and increase
insulin supply but change to 0.45% saline with 5% dextrose when BG
falls below 14 mmol/l (250 mg/dl).
Sodium:
Give 0.45% saline with 5% glucose, carefully monitor electrolytes, and
change to 0.9% saline if plasma Na concentration is falling.
Potassium:
Monitor electrolytes. After surgery, add potassium chloride 20 mmol to each
litre of intravenous fluid.
 .

67. T2 DM
 For those individuals who have type 2 diabetes and are treated with
insulin, follow the insulin guidelines as for elective surgery, depending on
type of insulin regiment.
 Patients on oral treatment:
 Metformin : discontinue at least 24 hours before the procedure for elective
surgery. In the event of emergency surgery and metformin I stopped < 24
hours before surgery, insure optimal hydration with IV fluids before ,during
and after surgery.
 Sulfonylureas or thiazolidinediones: stop for the day of surgery.
 Monitor blood glucose hourly and if greater tha 10mmol/l (180mg/dl) treat
with IV insulin, as for elective surgery, to normalise levels, or SC insulin if it
is aminor procedure.
ISPAD-Management of childhood& adoloscence diabetes guidelines 2011

68. CONTROVERSIES IN DM

69. GLYCEMIC CONTROL
PATIENT POPULATION BLOOD GLUCOSE
TARGET
RATIONALE
GENERAL
MEDICAL/SURGICAL*
FBS – 90-126mg/dl
RANDOM- <200mg/dl
Decreased mortality , infection
rates, shorter length of stay.
CARDIAC SURGERY* < 150mg/dl Decreased mortality , sternal
wound infection rates.
CRITICALLY ILL # <150mg/dl Mortality, morbidity , length of
stay.
ACUTE NEUROLOGICAL
DISORDER ^^
80- 140mg/dl Lack of data , concensus on
specific target, consensus for
controlling hyperglycemia.
* AMERICAN DIABETIC ASSOCIATION
# SOCIETY OF CRITICAL CARE MEDICINE
^^ AMERICAN HEART ASSOCIATION/AMERICAN STROKE ASSOCIATION

70. CONTD…
Tighter control(80-110mg/dl):
No added advantage, but more risk of
hypoglycemia.
Higher glucose – adverse outcome.
 In the virtual absence of clinical studies in general surgery, and
considering the basic biological data on the harmful effects of
hyperglycaemia, it is reasonable to recommend that blood
glucose should be maintained in the range 6 to 10 mmol/L, if this
can be achieved safely. A range from 4-12 mmol/L is acceptable.
*
* 1.NICE GUIDELINES- APRIL 2011, * 2.AMERICAN DIABETIC ASSOCIATION. * 3.ISPAD-GUIDELINES 2011

71. FLUID & INSULIN
 Since long time gold standard for controlling metabolic
consequences of DM during surgery & starvation –
glucose,insulin,potassium..
 ALBERTI&THOMAS described GIK Regimen, but lactate
containing solutions were not recommended since it
exacerbate hyperglycemia.
 Later many regimens were used, finally the most widely
practised is the sliding scale regimen.

72. CONTD…
 The terminology VARIABLE RATE INTRAVENOUS INSULIN
INFUSION(VRIII) is preferred for sliding scale.
 Advantages of VRIII :
• Flexibility for independent adjustment of fluid and insulin
• Accurate delivery of insulin via syringe driver
• Allows tight blood glucose control in the intra-operative
starvation period.

73. FLUID MANAGEMENT
(IN PATIENTS REQUIRING VRIII)
 NPSA(National patient saftey agency)- recommends hypotonic
fluids should be avoided. So 5% dextrose alone cantbe used.
 0.45%saline,5%dextrose,potassium,though isotonic in vitro, its
hypotonic in relation to plasma  causes
hyponatremia(particularly children)
 Replacing with 0.9%saline cause sodium& chloride overload.

74. CONTD…
 Since no randomised trails demonstrate superiority of any fluid, and until
there are clincal studies to verify safest solution
• THE RECOMMENDATION IS
• 0.45%SALINE,5%DEXTROSE&0.15%KCL as first choice.
FOR PATIENTS NOT REQ VRIII
• Ringers lactate/acetate, Hartmanns solution is used.
• 0.9%saline hyperchloremic acidosis.
* Management of adults with diabetes undergoing surgery and elective procedures: improving
standards- NHS(National institute for health and clinical excellence ) APRIL 2011

75. METFORMIN
Metformin does not worsen renal function.
For major surgery, metformin should be stopped on the day of
surgery and recommenced(24hr P.O) if serum creatinine level
does not deteriorate post-operatively.
Prolonged cessation of metformin will result in deterioration
of glycaemic control and additional anti-hyperglycaemic
treatment will be required.
Metformin need not be stopped for minor surgery.
Metformin & I.V radiocontrast
Creatinine : < 1.4mg/dl  safe to continue(need monitoring)
> 1.8mg/dl  withdraw 48 hrs.
*PERIOPERATIVE DIABETES MANAGEMENT GUIDELINES-AUSTRALIAN DIABETES SOCIETY MAY 2011

76. FUTURE STRATEGIES FOR TREATING
DIABETES
 Noninjectable routes of insulin administration (inhaled,
oral, nasal, transdermal)
 New injectable insulin formulation
 Implantable insulin pump
 Noninvasive continuous glucose sensors
 New islet transplantation
 Medication such as INGAP (islet neogenesis-associated
protein) peptide, which may cause regrowth of normally
functioning islet cells

77. SUMMARY
 Ensure glycemic control.
 Proper preop assessment
 Hourly blood sugar monitoring.
 Target blood sugar 5-10mmol (90-180mg/dl).
 Substrate fluid 0.45%NS,5%Dextrose,0.15%KCL
0.9%NS / Hartmanns solution.
 Avoid prolong fasting, start I-G Infusion.
 VRIII – more flexible.

78. TTHHAANNKK YYOOUU