Identify the risk and complication of Diabetes to the patient undergoing surgery

1. PERIOPERATIVE
MANAGEMENT OF THE
DIABETIC PATIENT
Dr. Somtochukwu Igboanugo
MBBS

2. Which of the following is not a Surgical risk in a
Diabetic Patient?
A. Infection
B. Myocardial infarction
C. Pressure Sore
D. Poor Wound healing
E. Poor Pain control
Question
Which of the following is not a Surgical risk in a
Diabetic Patient?
A. Infection
B. Myocardial infarction
C. Pressure Sore
D. Poor Wound healing
E. Poor Pain control
Ans:E

3. What levels of BSL do you consider
hyperglycemia?
What levels of BSL(BM) do you consider
hyperglycemia?
Question
Capillarybloodglucose(CBG)targetrangesarecontroversial.AimforCBG
between6-10mmol/Lbut6-12mmol/Lisacceptable.Avoidwideswings
inCBG.

4. To identify Risks and complications of
diabetes mellitus
 To identify Factors leading to poor outcomes
following surgery
 Understand recommended Theatre and
recovery care for Diabetics.
 Understand recommended Post-operative
and discharge care for Diabetics
Aim

5.  Introduction
 Definition of Diabetes
 Implications of Surgery on a DIabetic
 Risks and complications of diabetes mellitus
 The high-risk surgical patient and the impact of Diabetes
 Factors leading to poor outcomes
 Goals of perioperative diabetic management
 Pre-operative evaluation
 Variable rate intravenous insulin infusion (VRIII)
 Theatre and Recovery
 Post-Operative Care
 Discharge
 Important points to remember
Outline

6. INTRODUCTION
 Diabetes is the most common metabolic disorder,
affecting at least 6-7% of people in the UK1.
 With the rise in Obesity it is predicted it is predicted that
in the next decade, there would be an increase in
prevalence by 50%1.
 With recent data obtained from from the National
Diabetes Inpatient Audit it is predicted that at least 10%
of patients undergoing surgery have diabetes and this
percentage is also likely to rise1.

7. INTRODUCTION ctd
 Patients with diabetes have a higher risk of cardiovascular
disease and higher perioperative risk.
 Doctors and Nurses caring for patients with diabetes
should be familiar with the risks attached to having
diabetes, and to the particular risks of the particular
surgery and of anaesthesia in patients with diabetes.
 Through careful glycaemic management in perioperative
period, we may reduce morbidity and mortality and
improve surgical outcomes.

8. WHAT IS DIABETES?
 Diabetes is a chronic, metabolic disease characterized by
elevated levels of blood glucose (or blood sugar) with
multiple end-organ damage4.
 Type 1 diabetes, once known as juvenile diabetes or
insulin-dependent diabetes, is a chronic condition in
which the pancreas produces little or no insulin by itself4.
 Type 2 diabetes, the most common, usually in adults,
which occurs when the body becomes resistant to insulin
and overtime doesn't make enough insulin4.
Aka: Diabetes Mellitus

9. Risks and complications of
diabetes mellitus
 Patients with diabetes mellitus are at risk of the complications of the
disease. It is worth considering these in outline when considering how best
to care for patients with diabetes undergoing surgery3.

10. Implications of Surgery on a
Diabetic
 Metabolic effects of starvation: Period of starvation induces a catabolic
state. It will stimulate secretion of counter-regulatory hormones.
 Metabolic effects of major surgery:
 counter- regulatory hormones (epinephrine, glucagon, cortisol and growth
hormone)
 inflammatory cytokines IL-6 and tumor necrosis factor-alpha.
 Hypoglycemia: Exacerbate the catabolic effect of surgery.

11. Risks and complications of
diabetes mellitus
 Patients with diabetes mellitus are at risk of the complications of the
disease. It is worth considering these in outline when considering how best
to care for patients with diabetes undergoing surgery3.
 The following risks and observations are worth considering in patients with
diabetes undergoing surgery:
1. Myocardial infarction postoperatively.
2. Renal complications, worse with those with co-existing Diabetic Nephropathy.
3. Infection1:
 Postoperative Wound Infection: SSIs
 Other infections such as chest and urinary infections are more common in those with
diabetes.

12. Risks and complications of
diabetes mellitus ctd.
4. Stroke and CVA related events
5. Heel pressure sores, particularly with peripheral neuropathy.
6. Disruption and worsening of Diabetes control(for example, from the stress
of surgery, lack of oral intake, postoperative vomiting, etc).
7. Poor Wound Healing

13. The high-risk surgical patient and
the impact of Diabetes
impact of diabetes
 The high-risk surgical population is made up of elderly patients with
co-existing medical conditions undergoing complex or major
surgery, often as an emergency1.
 There is clear evidence that such diseases are strongly associated
with poor outcomes after major surgery1
 Hence, High-risk individuals with Diabtes would require closer
monitoring.

14. Factors leading to poor outcomes
 Failure to identify patients with diabetes1
 Lack of institutional guidelines for management of diabetes1
 Poor knowledge of diabetes amongst staff delivering care1
 Complex polypharmacy and insulin prescribing errors1

15. Goals of perioperative diabetic
management
Avoidance of hypoglycemia or marked
hyperglycemia
Maintenance of fluid/electrolyte balance
Return to stable glycemic control as soon as
possible
Prevention of ketoacidosis/hyperosmolar states

16. PRE-OPERATIVE EVALUATION
 Diabetes should be well controlled prior to elective surgery, aiming for an
HbA1c of less than 69mmol/mol, if it safe to do so1
 The patient’s diabetes care provider should be involved in the
management of their patient’s diabetes peri-operatively.
 Patients with diabetes should be on the morning list, preferably first on the
list1.
GENERAL PRINCIPLES

17. PRE-OPERATIVE EVALUATION ctd.
 Patients should be well hydrated before the procedure.
 During venous thromboembolism risk assessment ensure no
contraindications to anti-embolism stockings e.g. patients with peripheral
vascular disease or neuropathy.
 Patients with ‘at risk’ feet should be identified and steps taken to
document this clearly.
GENERAL PRINCIPLES

18. VARIABLE RATE INTRAVENOUS
INSULIN INFUSION (VRIII)
 The VRIII is the preferred method of controlling the surgical patient’s serum
glucose in the following circumstances:
 Patients anticipated to have a long starvation period (i.e. 2 or more missed
meals)
 Decompensated diabetes
 Preparation and Administration
 Some institutions use prefilled syringes and where available, these should be
used according to local policies
 Make up a 50ml syringe with 50 units of Soluble Human Insulin (e.g. Human
Actrapid®) with 49.5ml of 0.9% sodium chloride solution.
 To ensure a steady supply of substrate and to ensure the RDA for sodium is
met, it is recommended that 5% glucose in 0.45% saline and 0.15%/0.3%
potassium chloride should always be run alongside the VRIII at a rate to
meet the patient’s fluid maintenance requirements
GENERAL PRINCIPLES

19. Theatre and Recovery
 Maintain intraoperative blood glucose level between 6-10mmol/L where
possible. The target blood glucose in the pre-operative, anaesthetized or
sedated patient should be 6-10mmol/L (up to 12mmol/L may be
acceptable)1.
 Maintain normal electrolyte concentrations1.
 Optimise intra-operative cardiovascular and renal function1.
 Provide multi-modal analgesia with appropriate anti-emetics to enable
an early return to a normal diet and usual diabetes regimen1.
 Avoid pressure damage to feet during surgery1.
GENERAL PRINCIPLES

20. POST-OPERATIVE CARE
 Ensure blood glucose levels are appropriately maintained. The
acceptable post-operative range in the awake patient not on a
VRIII is 4-12mmol/L, however if a VRIII is used, then the acceptable
range remains.
 Fluid and electrolyte balance should be monitored and
maintained.
 Encourage an early return to normal eating and drinking,
facilitating return to their usual diabetes regimen.
 Treat post-operative nausea and vomiting to promote normal
feeding.
 Maintain meticulous infection control.
 Inspect foot and pressure areas regularly.
Recommendations

21. Discharge
 Ensure early discharge determined by pre-agreed clinical and social
criteria1.
 Ensure that plans are in place for safe management of diabetes post
discharge1.
 Provide patient education to ensure safe management of diabetes on
discharge1.
 Discharge should not be delayed solely because of poor glucose control.
The patient or carer’s ability to manage the diabetes should be taken into
consideration.
Recommendations

22. Important Points to remember
 Diabetic patients have greater risk of complications.
 Poorly controlled diabetes carries high risk of wound
infections.
 Diabetic cases should be operated on first.
 Patients with diet or tablet controlled diabetes may be
managed using a policy of omitting medication and
checking blood glucose levels regularly. Diabetics who are
poorly controlled or who take insulin may require a
intravenous sliding scale. Potassium supplementation should
also be given.

23. Important Points to remember
 Careful planning, taking into account the specific needs of
the patient with diabetes, is required at all stages of the
patient pathway from GP referral to post-operative
discharge1.
 Early pre-operative assessment should be arranged to
determine peri-operative diabetes management strategy
and to identify and optimise other comorbidities1.
 The term ‘variable rate intravenous insulin infusion’ (VRIII)
should replace the ambiguous term ‘sliding scale’.
 Patients expected to miss more than one meal should have
a VRIII.

24. Important Points to remember
 On Peri-operative Blood Glucose Monitoring.
 Capillary blood glucose (CBG) levels should be monitored
and recorded at least hourly during the procedure and in
the immediate postoperative’.
 The WHO surgical safety checklist bundle should be
implemented. The target blood glucose in the pre-
operative, anaesthetised or sedated patient should be 6-
10mmol/L (up to 12mmol/Lmay be acceptable).
 In the post-operative period, Fluid and electrolyte balance
monitoring as well as an early return to normal eating and
drinking, facilitating return to their usual diabetes regimen
should be encouraged.

25. More Resources
 Joint British Diabetes Societies for Inpatient Care (JBDS-IP)
Management of Adults with Diabetes undergoing surgery
and elective procedures: Improving standards Summary
handbook

26. References
1. Management of adults with diabetes undergoing surgery and
elective procedures: improving standards. Summary. Revised March
2016
https://www.diabetes.org.uk/resources-s3/2017-
09/Surgical%20guideline%202015%20-
%20summary%20FINAL%20amended%20Mar%202016.pdf
2. Precautions for Patients with Diabetes Undergoing Surgery
http://www.diabetologists-
abcd.org.uk/JBDS/JBDS_IP_Surgery_Adults_Full.pdf
3. Precautions for Patients with Diabetes Undergoing Surgery
https://patient.info/doctor/precautions-for-patients-with-diabetes-
undergoing-surgery
4. Diabetes
https://www.who.int/health-topics/diabetes
5. Rockman CB, Saltzberg SS, Maldonado TS, et al; The safety of carotid
endarterectomy in diabetic patients: clinical predictors of adverse
outcome. J Vasc Surg. 2005 Nov42(5):878-83

27. THANK YOU