DM

1. Peri-operative Management of
Diabetes Patients
Department of Diabetes & Endocrinology
Yangon General Hospital

2. Peri-operative diabetic control
 Aims : maintain good glycemic control throughout
: maintain normal electrolyte concentrations
: optimize intra-operative cardiovascular and renal function
to reduce the post operative complications and mortality
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3. General guidance
 Modern management of the surgical patient with diabetes
focuses on:
- thorough pre-operative assessment
- optimization of glycemic control
- careful intra-operative and post operative management
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4. Types of surgery
 Minor surgery means:
- day case or overnight stay, likely to resume normal
oral intake within 12 hours (missing only one meal)
 Major surgery means:
- unlikely to resume normal intake more than 12 hours
(missing 2 meals or more)
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5. Pre operative assessment for Diabetes Mellitus
1. General Assessment
- presence of cardiac, renal and neurological sequelae of Diabetes
2. Assessment of Glycemic control
- Desired preoperative HbA1C is < 8.5% (8 - 9% is acceptable
depending on individual)
- Recommended target : 4 - 6 mmol/L (pre meal) and < 10 mmol/L
(2HPP)
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6. Elective surgery
(a) Minor surgery
Patients on diet alone or oral hypoglycemic agents ( OHA)
 - Omit OHA on the day of the operation
 - Check capillary blood glucose before and after the operation
 - If blood glucose is 4 -10 mmol/L (70-180mg/dl), simple
observation is required
 -If blood glucose is > 10mmol/L (180mg/dl), consider the
need for glucose-potassium-insulin infusion(GKI) or variable
rate intravenous insulin infusion ( VRIII )
 -If blood glucose <4mmol/L (70mg/dl), treat as
hypoglycemia
 -Restart OHA after the operation once the patient has had the
first meal 6

7. Elective surgery
Patients on insulin
 Omit morning insulin on the day of the operation
 Check capillary blood glucose before and after the operation
 - If blood glucose is 4 - 10 mmol/L (70-180mg/dl), simple observation is
required
 -If blood glucose is >10mmol/L (180mg/dl), consider the need for glucose-
potassium-insulin infusion(GKI) or variable rate intravenous insulin
infusion ( VRIII )
 -If blood glucose < 4mmol/L (70mg/dl), treat as hypoglycemia
 -Restart usual insulin and diet after the operation
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8. Elective surgery
(b) Major surgery
Patients on diet alone or OHA
 Omit OHA on the day of the operation
 Commence GKI or VRIII 2 hours before the operation
 Monitor the blood glucose hourly pre, intra and post operatively
 Stop GKI or VRIII and restart the usual medication only when the
patient is eating and drinking normally
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9. .Patients on insulin
 Omit subcutaneous soluble or rapid acting insulin and mixed insulin on the
day of the operation
 Long acting (basal; Glargine) insulin is usually continued at normal time even
when the patient is on GKI or VRIII
 If the surgery is planned in the evening and patient is having breakfast,
administer half the normal breakfast insulin
 Commence GKI or VRIII two hours before the operation
 Monitor blood glucose hourly pre, intra and post operatively
 If blood glucose < 4 mmol/L (70mg/dl), treat as hypoglycemia
 When the patient is eating and drinking normally, start normal dose of insulin
with the first meal and stop the GKI or VRIII 60 minutes later
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10. Emergency Surgery
 There will be no opportunity for pre admission planning
 If the blood sugars are > 250 mg/dl and signs of
decompensation (acidosis, hypotension), check urine/blood
ketones /electrolytes
 If ketones is positive, postpone operation , refer to physicians
and treat as DKA
 If blood sugars rises above 10mmol/L(180mg/dl) , GKI or
VRIII should be commenced and continued until the patient
finishes operation and starts eating and drinking
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11. Post operative care
Aims
 Ensure the glycemic control, fluid and electrolyte balances are
maintained
 Aim for capillary blood glucose level in the 5.6 -10 mmol/L (100-
180mg/dl) where this can be achieved safely
 Monitor the fluid and electrolyte daily and prescribe appropriate
fluid
 Encourage an early return to normal eating and drinking,
facilitating return to usual diabetes regimen 11

12. Glucose-Potassium-Insulin infusion (GKI)
 GKI infusion avoid the risk associated with running IV
glucose and IV insulin through separate lines
 If one canula becomes blocked, the patient may become
hypo- or hyperglycemia.
 However GKI infusions are not suitable in poorly
controlled diabetes or patients who are very unwell
(where close serum glucose monitoring is required)
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13.  Take a 500ml of 10% glucose and add soluble insulin according
to the table below
 The insulin should be injected into the bag according to
following table and mixed thoroughly
 Add 10 -20 mmol of KCl (Note: omit KCL if patient has renal failure or
pre-op: K+ > 5mmol/L)
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Blood glucose
mmol/L (mg/dl)
Insulin (units) in
each
500 ml bag
Serum potassium
(mmol/L)
KCL to be added
(mmol/bag)
<4 (<70) Treat as
hypoglycemia
<3 20
4-6 (70-110) 6 3-5 10
6-10 (110-180) 10 >5 None
10-20 (180-360) 15
>20 (360) 20

14.  Run infusion at 100ml/hr
 Target glucose 5.6 -10 mmol/L (100 -180 mg/dl)
 Each change in units of insulin per bag requires a new bag
 It is not acceptable to allow blood glucose levels to be
consistently > 10 mmol/L (180 mg/dl) and hypoglycemia < 4
mmol/L (<70 mg/dl) should be avoided
 If the patient has significantly impaired renal function (eGFR
< 30), the patient may need a reduced insulin dose or a reduced
infusion rate
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15.  The patient who is insulin resistant (obese, infection, steroid
therapy) needs more insulin (2-6 more units)
 The pre-, intra and post-op blood glucose is stable, the post-op
blood glucose may be checked 2 hourly
 Change to subcutaneous insulin when eating normally. It is
important to continue the IV insulin infusion for 60 minutes
after the first subcutaneous insulin injection has been given
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16. Variable rate intravenous insulin infusion (VRIII)
 This is alternative to the GKI infusion, which is more suitable and practical
for very ill patients peri- or post-operatively
 It involves separate infusion of glucose and insulin in two different lines
 Target glucose 5.6 -10 mmol/L (100 -180 mg/dl)
It is not acceptable to allow blood glucose levels to be consistently > 10
mmol/L (180 mg/dl) and hypoglycemia < 4 mmol/L (<70 mg/dl) should be
avoided
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17. VRIII
Insulin preparation
 A 50 ml syringe with 50 units of soluble insulin with 49.5 ml of 0.9%
sodium chloride solution (syringe pump )
 A 250 ml of 0.9% sodium chloride solution with 250 units of soluble insulin
(infusion pump/flow meter)
 A 500 ml of 0.9% sodium chloride solution with 25 units of soluble insulin
 (7 drop/min = 1 unit/hr )
 - Dose adjustment by monitoring RBS hourly
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18.  Rate of VRIII
 Initial dose and subsequent adjustment can be done according
to variable scale depending on RBS level and response to
insulin as follow.
Capillary blood
glucose
Reduced Rate Standard Rate Increased Rate
< 70 mg/dl Inpatient hypoglycemia
policy
Inpatient
hypoglycemia policy
Inpatient hypoglycemia
policy
70-109 mg/dl 0 unit 0 unit 0 unit
110-144 mg/dl 0.5 unit 1 unit 2 units
145-214 mg/dl 1 unit 2 units 4 units
215-289 mg/dl 2 units 4 units 6 units
290-360 mg/dl 3 units 5 units 7 units
361-435 mg/dl 4 units 6 units 8 units
> 435 mg/dl 5 units 8 units 10 units

19. Rate of VRIII
 Reduced rate - insulin sensitive patients (i.e. < 24 unit/day),
lean or elderly patients or low basal or meal insulin doses
 Standard rate - use unless otherwise indicated
 Increased rate - insulin resistant patient (i.e. >100 unit/day),
patient on steroids, TPN, or tube feeding
or high basal or meal insulin doses
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20. Substrate infusion
Fluids to run alongside the VRIII
 5 -10 % dextrose water 500 ml and 10 mmol of KCl at a rate of 40
ml/hr
 Check serum potassium daily
If K+ >5.5 mmol/L No KCl
If K+ 3.5-5.5 mmol/L 10 mmol of KCl
If K+ < 3.5 mmol/L 20 mmol of KCl
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21. Discontinuation of insulin infusion
 Patient tolerating at least 50% of normal oral intake
or enteral feeding
 1 or 2 hours before discontinuing the insulin infusion,
initiate alternative glycemic management
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22. DIABETES AND CKD
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23. Diabetes Nephropathy( Diabetes Kidney disease)
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24. Scope of diabetes kidney disease

25. In type 2 diabetes natural history is same but progress is less
predictable and > 50% die of CAD rather than renal failure
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26. CKD-CVD-Diabetes Link: CKD is a Disease Multiplier

27. Risk factors for diabetes nephropathy
 Hypertension
 Hyperglycemia
 Microalbuminuria
 Duration of diabetes
 Family history
 Ethnicity
 Cigarette smoking
 Hyperlipidemia
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28. Screening for microalbuminuria
 Test for microalbuminuria annually in all type 2 diabetes
subjects starting at diagnosis
 Type 1 diabetes of more than 5 years duration
Methods
 Measurement of the albumin to creatinine ratio in a random spot
collection
 24 h collection with creatinine, allowing the simultaneous
measurement of creatinine
 Timed collection
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29. DM Nephropathy
 presence of dipstick +ve proteinuria in a
person with diabetes ( >300mg/day )
Incipient nephropathy
 Urinary ACR 2.5 -30mg/mmol (men)
3.5-30mg/mmol (women)
 Urine microalbumin 30-300 mg/24 hour
20-200microgram/min

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31. CKD and anti-diabetic drugs
 Biguanides – contraindicated if eGFR <30; reduce dose if eGFR is
between 30-45
 Sulphonylureas are best avoided; shorter acting agents like glipizide
and gliclazide may be used in mild to moderate renal insufficiency
 Repaglinide is safe in kidney failure
 Glitazones and acarbose are best avoided
 Sitagliptin, saxagliptin and vildagliptin can be given with dose
adjustment and linagliptin can be used without dose adjustment
 Insulin is the antidiabetic agent of choice; regular insulin and rapid
acting analogues are preferred 31

32. Blood pressure control in CKD
The ADA states that all patients with diabetes should aim to
keep their BP <140/90 mm Hg
However, individuals with proteinuria may be candidates for
tighter BP control, if this can be achieved without significant
side effects
 Drugs blocking the Renin Angiotensin Aldosterone System
(RAAS) are the antihypertensive agents of choice.
 ACEI or ARB : should be the first choice
 ACEI can be used even serum creatinine rise above 200 mg/dl
providing that patient is planned for dialysis
 Dual therapy is not advisable because of hyperkalemia
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33. Others
 Protein restriction can reduce hyperfiltration and
intraglomerular pressure
 0.8mg/kg/day RDA is recommended by ADA
 Salt restriction is advisable
 Avoid nephrotoxic drugs, eg : NSAID
 Stop smoking
 Aggressive treatment of UTI
 Lipid lowering therapy : Statins can reduce CVD risk but
reduce dose of rosuvastatin
 Refer to Nephrologist if EGFR < 45 and Joint care is utmost
important
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34. Thank You
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