Periop management of dm ajay

Dr. Ajay Kantharia M.D.
Hon. Physician & Intensivist :
Saifee Hospital
Sir H.N. Hospital
Smt. Dalvi Hospital
In Charge of ICU :
Dr. Bacha’s Nursing Home

Diabetes mellitus (DM) is a group of
metabolic diseases of impaired
glucose homeostasis , due to
absolute or relative lack of Insulin

Abnormality of glucose can be due to:
a defect in insulin secretion,
increased insulin resistance,
increased endogenous glucose
production by the liver or
any combination of these factors.

The incidence of type I diabetes remains fairly fixed at 0.4% of the population.
The prevalence of type II DM is dramatically increasing. It is expected that the number of people with DM will increase from the 150 million today to 300 million by the year 2025 globally.

Diabetes is associated with
an increased requirement for surgical procedures and
increased postoperative morbidity and mortality.
Increased chance of complications

The stress of surgery itself results in metabolic disturbances that alter glucose homeostasis.

Glucose Homeostasis

Glucose Homeostasis
Glucose homeostasis is controlled primarily by the anabolic hormone insulin.

The catabolic hormones glucagon, catecholamine, cortisol, and growth hormone oppose the action of insulin. They are known as anti-insulin or counter-regulatory hormones.

Any stress (surgery, trauma, anesthesia, burns, or infection) is associated with increased metabolic demands and can affect glucose metabolism.

In the first phase of the stress response there is vasoconstriction, which limits blood loss after injury.
Fuels are mobilized from all available sources, but the provision of glucose for the brain has first priority.

High concentrations of epinephrine and glucagon stimulate glycogenolysis and gluconeogenesis.
This leads to moderate hyperglycemia.
Decreased peripheral uptake of glucose enhances the hyperglycemic effect.

Stress also induces insulin resistance in muscle, adipose tissue, and liver, probably at a post receptor level.
The insulin- dependent transport of glucose in adipose tissue and skeletal muscle decreases.

The type of anesthesia used during surgery may also influence the hyperglycemic response during surgery.
General anesthesia has been shown to result in higher blood glucose concentration, circulating catecholamines, cortisol, and glucagon compared to local and epidural analgesia.

Blood Glucose and Perioperative Outcome
Hypoglycemia
OR
Uncontrolled DM can lead to
volume depletion from osmotic diuresis
life-threatening conditions such as diabetic ketoacidosis and non-ketotic hyperosmolar coma

Other Problems
Increased thrombogenesis
Hypertension
Infection
Overall cost increases

Perioperative Risk Assessment
All the underlying medical problems should be noted and addressed before surgery.
An important aspect of perioperative assessment is glycemic control .

Preoperative Assessment
“ Fitness for surgery”
What is the difference in other surgical patients & a Diabetic patient?

Check Medical history
CVS, RS, GI, CNS
H/o DM.. Duration, medication past and present, dosage
How is the glycemic control
Any diabetic complications… retinopathy, nephropathy etc

Check Renal function
Urine, Creatinine,
Analgesics
Hypoglycemic episodes,… frequency, awareness….

Check the drugs and names

Check the dietary history

Hard Working OR Hardly working

Surgical details
What is the surgery?
Which anesthesia?
Time?
Duration?
Post op ICU? Wards?

Surgery can be defined as:
Minor (those that do not require post op fasting)
or
Major (any procedure requiring general anesthesia for more than two hours and
requiring fasting)

Type I Diabetes
In type I diabetics, adequate glucose should be provided to prevent catabolism and starvation ketosis.
The physiologic amount of glucose required to prevent catabolism in the average nondiabetic adult is
5 gram/hr .

Plan should be to keep Blood sugar between 150 to 180 mg%.
Potassium replacement is required

4 common scenario:
(1) Type 1 DM for Minor surgery
(a) With fasting
(b) Without fasting
(2) Type 1 DM for major surgery
(3) Type II DM for Minor surgery
(a) With fasting
(b) Without fasting
(4) Type II DM for Major surgery

Type 1 DM (Minor Surgery)
Patients who require fasting for minor surgery should not be administered their usual dose of insulin.
Glucose and electrolytes must be measured on the day of surgery. D5 NS (DNS) should be initiated. If the blood glucose is more than 200 mg/dl, rapid acting insulin should be given.

Type 1 DM (Minor Surgery)
Patients for minor surgery and do not require fasting should be administered one half of their daily dose of insulin and eat their regular food.
If the blood glucose is between 100-200 mg/dl, surgery can be done.
If the blood glucose is >200, 1/2NS and 10 mEq of potassium should be added to each 500 ml of the above solution, along with rapid acting insulin.

Type 1 DM (Major Surgery)
For major surgery, regular insulin is administered intravenously in an infusion of 10% of dextrose in 1/2NS to which potassium chloride has been added (0.3 units of regular insulin per gram of glucose) and infused at 100ml/hr. (15units for one pint)

Intravenous Insulin
Intermittent IV Bolus
OR
Continuous IV Infusion
Single solution Glu- Pot- Insulin Drip
Separate Insulin drip

Intravenous Insulin Intermittent Bolus
In the intermittent bolus technique,
10 U of regular insulin is administered every 2 hours and supplemented by
5 U every 60 minutes for blood glucose levels greater than approximately 200 mg/dL.

Intravenous Insulin Continuous Infusion
500 cc N.Saline + 50 units of regular insulin.
Start at 1unit / hour
(10ml / hour)
50cc N. Saline + 50 units of regular insulin
1 unit / hour ~ 1 ml / hour

It is important to remember that patients with type 1 diabetes have basal insulin requirements that must be met, even during fasting, to maintain metabolic control.

Type II Diabetes (On Diet alone)
NBM before surgery
Hydration as per requirement
Regular monitoring of Blood Sugar
Small boluses of Short Acting Insulin
May be able to stop insulin in few days

Type II Diabetes
Patients undergoing minor surgical procedures and who are not fasting should be managed by using their normal diabetic regimen.
Preferably, surgery should be performed in the morning.
Patients who are taking oral hypoglycemic agents should continue their medication and eat their regular food.

Type II DM ( Major Surgery)
Major surgery OR Minor surgery (requiring fasting )
Patients should take regular medication, except for those who take second generation sulfonylureas (glipizide, glimepiride, glyburide).
These agents should be stopped one day before surgical procedure because of their prolonged half-lives.

Metformin, despite its short half-life should be stopped one day before, since it increases the risk of lactic acidosis due to perioperative dehydration, renal hypo-perfusion and tissue hypoxia.
Metformin should be restarted only after establishing normal renal function.

All other oral hypoglycemic agents can be continued until the day of surgery, at which time patients are instructed not to take their normal morning dose.

Intraoperative Glucose requirement
Patients with diabetes should receive approximately 5 g of glucose per hour (i.e., 5 % dextrose solution in water infused at 100 mL per hour) during surgery to prevent the development of hypoglycemia, ketosis, or protein breakdown.

Intraoperative Glucose requirement
5% Dextrose @ 100 ml / hour
10% Dextrose @ 50 m/ hour

Postoperative Management
All diabetic patients who undergo major surgery should resume their normal dietary regimen and oral medication or insulin as soon as possible.
Intravenous infusion of D5 NS should be discontinued once this has been accomplished.

Type I diabetics who undergo minor surgical procedures should have their blood sugars checked every 4 hours. If the blood glucose levels is >250 mg/dl, subcutaneous (SC) rapid acting insulin should administered.

For patients undergoing outpatient surgery, their preoperative regimen may be reinstituted when the patient resumes eating.
An exception to this approach exists when the procedure is performed in conjunction with iodinated radiocontrast dye and the patient is treated with a biguanide.
The biguanide should not be resumed for 72 hours postoperatively, when serum creatinine is measured to document the absence of dye-induced renal toxic effects and normal renal function.

If unstable DM control….
start insulin infusion

Post op Surgeon’s order
1 .. 5% dextrose
1.. Ringer lactate
1.. DNS
1.. N S
1.. 5% dextrose

Few common problems
In a diabetic patient:
Autonomic neuropathy / gastroparesis
Vomiting / constipation
Urine retention

Thank You

Periop management of dm ajay

by Dr. Ajay Kantharia

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