This document discusses diabetes, its classification, signs and symptoms, and management in surgical patients. It notes that diabetes is a chronic condition characterized by high blood glucose resulting from insulin deficiency or resistance. It also discusses the increased risks that diabetic patients face during surgery due to hormonal and metabolic responses to trauma. The document provides guidelines for evaluating, monitoring, and controlling blood glucose levels in diabetic patients before, during, and after surgical procedures.

1. PRESENTED BY-
DR. NESAR AHMAD
MODERATOR-
DR. SIMEEN USMANI
D/O JARAHAT, AKTC, AMU

2. Diabetes
 Diabetes is a clinical syndrome of hyperglycaemia with
glycosuria resulting from insulin deficiency or intolerance
 It is a chronic disorder of carbohydrate, fat and protein
metabolism.
 Approximately 10% of patients admitted to hospital have
diabetes
 Globally it is estimated that 451 million people had diabetes in
2017 in which 72 million cases of diabetes recorded in India
 50% of all diabetic patients present for surgery during their
lifetime

3. •Perioperative morbidity and mortality are greater in diabetic than in
non-diabetic patients
•Diabetic patients have up to 50% higher peri-operative mortality
than in non-diabetic patients
•Globally diabetes caused 5 million deaths in 2017
•Someone in the world dies from complications associated with
diabetes every 10 seconds
•Diabetics have health expenditures that are 2.3 times higher than
non-diabetics.

4. Etiological Classification of DM
I. Type – 1 IDDM (insulin dependent
diabetes mellitus)
Its Sub-divided into:
A. Immune Mediated (Islet cell
antibodies)
B. Idiopathic (No antibodies)
II. Type – 2 NIDDM (non insulin
dependent diabetes mellitus)
III. Other specific types of diabetes:
A. Genetic defect of beta cell
function characterised by
mutations
B. Genetic defects in insulin action
C. Diseases of the exocrine pancreas-
pancreatitis, neoplasia, cystic
fibrosis, hemochromatosis etc.
D. Endocrinopathies- Acromegaly,
Cushing’s syndrome, Phaeochromo
-cytoma, hyperthyroidism
E. Drug Induced Diabetes - Due to
steroids ,Thiazides, thyroid hormone,
phenytoin, etc.
F. Infections- rubella, cytomegalovirus
etc.
G. Other Genetic Syndrome associated
with diabetes i.e. Lipodystrophies,
muscular dystrophy, Klinefelter’s
syndrome,Turner’s Syndrome,
Down’s Syndrome, etc.
IV. Gestational diabetes mellitus

5. Type 1 Diabetes Mellitus (Insulin Dependent)
 Type 1 diabetes or Insulin Dependent Diabetes Mellitus is also
known as juvenile diabetes.
 It usually occurs in childhood or early adulthood i.e. usually
begins below the age of 30 yrs.
 b/w 5-10% of individuals develop type 1 DM after age 30.
 It manifests itself in two ways:
 Classic Triad Of Type 1 Diabetes Mellitus : Polydipsia, Polyuria
and Polyphagia.
 Ketoacidosis: Patient present with Diabetic Ketoacidosis
following an acute infection or surgery as an first episode
without any apparent cause. In severe cases, patient may develop
mental apathy, confusion and may lapse into coma.

6.  Polygenic disorder thought to be of auto immune
aetiology
 Results in destruction of β cells in the Islets of
Langerhans in the Pancreas, with complete or near-
total insulin deficiency
 Endogenous insulin is required to maintain plasma
glucose levels to within physiological levels

7. Type 2 Diabetes Mellitus (Insulin Resistance)
 Type 2 diabetes mellitus or Non insulin dependent diabetes
mellitus, usually begins after the age of 40 years and 60 % of the
patients are obese. However young patients of type 2DM are also
seen nowadays.
 Type 2 DM occurs with intact beta cells of islets of langerhans,
but there is peripheral tissue resistance to insulin.
 There may be some decrease in insulin production or a hyper
insulin state.
 Hyperglycaemia resulting from reduced insulin secretion and
peripheral insulin resistance
 These patients usually does not develop Ketoacidosis.

8. • The plasma insulin levels are normal to high.
• Glucagon levels are high but resistant to insulin.
• T2DM leads to many health problems including cardiovascular
disease, stroke, blindness, kidney failure, neuropathy, impotency,
depression, cognitive decline and mortality risk from certain forms of
cancer.
• Premature death from T2DM is increased by as much as 80 percent
and life expectancy is reduced by 12 to 14 years
• Depending on severity, may be controlled with:
- Lifestyle intervention (Appropriate diet and exercise to lose
weight)
- oral hypoglycaemics
- insulin

9. Gestational Diabetes Mellitus
 GDM is hyperglycaemia with blood glucose values
above normal but below those diagnostic of diabetes,
occuring during pregnancy
 Women with GDM are at an increased risk of
complications during pregnancy and at delivery
 They and their children are also at increased risk of
type 2 diabetes in the future
 It is diagnosed through prenatal screening

10. Fasting Postprandial(2hr
GTT)
Normal <100 (5.6) <140(7.8)
Diabetes Mellitus ≥126 >200
Impaired Fasting
Glycaemia
100 - 125(5.6-6.9) <140(7.8)
Impaired Glucose
Tolerance
<126(7.0) ≥140 & 200(7.8 & 11.1)
Condition Venous Plasma Glucose Concentration in
mg/dl(mmol/L)

11. 1. Classic Symtoms of diabetes plus random plasma glucose level
≥ 200 mg/dL (≥ 11.1 mmol/L)
Random is defined as any time of day without regard to
time since last meal.
2. Fasting plasma glucose level ≥ 126 mg/dL (≥ 7.0 mmol/L)
Fasting is define as no caloric intake for at least 8 hrs
3. Two-hour plasma glucose level ≥ 200 mg/dL (≥ 11.1 mmol/L)

12. METABOLIC SYNDROME(syndrome x) AND RISK FACTORS ASSOCIATED WITH
DIABETES MELLITUS:
WHO DIAGNOSTIC CRITERION -
1.CONTROL OBESITY
BMI>30KG/METRE SQUARE
WAIST /HIP RATIO
MEN>0.90
WOMEN>0.85
2. TRIGLYCERIDE
>150mg/dl
3.HDL CHOLESTEROL
Men<35mg/dl
Women<39mg/dl
4. Fasting Glucose
>110mg/dl
5. Microalbuminurea
Urinary albumin excretion rate >/ =20 mu gm/min
DIAGNOSIS IS MADE WHEN 3 OR MORE OF THESE RISK FACTORS ARE PRESENT

13. 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.

14. Diabetes and Surgery
 Surgery is a form of physical trauma
 It results in catabolic stress and secretion of counter-regulatory
hormones (including catecholamines & cortisol) in both normal
and diabetic patients, resulting in increased glycogenolysis,
gluconeogenesis, lipolysis, proteolysis and insulin resistance.
 Starvation exacerbates this process by increasing lipolysis.
 The type of diabetes, amount of insulin dose, diet or oral
hypoglycaemic agents must be considered as this will change the
overall management plan
 The risk of significant end-organ damage increases with the
duration of diabetes, although the quality of glucose control is
more important than the absolute time

15. Factors Adversely Affecting
Diabetic Control Perioperatively
 Anxiety
 Starvation
 Anaesthetic drugs e.g. Opiates, benzodiazepine
 Infection
 Metabolic response to trauma
 Diseases underlying need for surgery
 Other drugs e.g. steroids

16. Metabolic & Hormonal Responses to
Surgery
 Hormonal
 Secretion of stress hormones
 Cortisol
 Catecholamines
 Glucagon
 Growth Hormone
 Cytokines
 Relative decrease in insulin
secretion
 Peripheral insulin resistance
 Metabolic
 Increased
gluconeogenesis and
glycogenolysis
 Hyperglycaemia
 Lipolysis
 Protein breakdown

18. Metabolic Response to Surgery and Diabetes
 Hypoglycaemia
 When the plasma glucose concentration is <55 mg/dl (<3.0
mmol/L) with symptoms of hypoglycemia
 Symptoms include behavioral changes, confusion, fatigue, seizure
loss of consciousness . If hypoglycaemia is severe and prolonged
death may occur.
 May develop perioperatively due to the residual effects of
preoperative long acting oral hypoglycaemic agents or insulin.
 Exacerbated by preoperative fast or insufficient glucose
administration
 Can lead to irreversible neurological deficits
 Dangerous in anaesthetised or neuropathic patient as the warning
signs may be absent
 Management
 Give i.v dextrose (25 gm) and monitor glucose levels

19. Metabolic Response to Surgery
and Diabetes
 Hyperglycaemia
 Glucagon, cortisol and adrenaline secretion as part of the
neuroendocrine response to trauma, combined with iatrogenic
insulin deficiency or glucose overadministration may result in
hyperglycaemia
 Causes osmotic diuresis, making dehydrated and organ
hypoperfusion, and increased risk of UTI
 osmotic diuresis, delayed wound healing, exacerbation of brain,
spinal cord and renal damage by ischaemia
 Results in hyperosmolality with hyperviscocity, thrombogenesis and
cerebral oedema
 Management
 Frequently measure blood glucose and administer insulin

20. Metabolic Response to Surgery and
Diabetes
 Ketoacidosis
 Any patient who is in a severe catabolic state and has an
insulin deficiency (absolute or relative) can decompensate
into keto-acidosis
 Most common in type 1 patients
 Increased risk postoperatively, often precipitated by the
stress response, infection, MI, failure to continue insulin
therapy.
 characterised by hyperglycaemia, hyperosmolarity,
dehydration (may lead to shock and hypotension) and
excess ketone body production resulting in metabolic
acidosis.

21. Metabolic Response to Surgery and
Diabetes
 Management
 restore intravascular volume
 eliminate ketonaemia
 control blood glucose
 replace electrolytes
 monitor glucose and ketone levels

22. Underlying Cardiac Complications of
Diabetes and Surgery
 Cardiovascular problems frequently present in long standing
diabetics
 Ischaemic Heart Disease
 Coronary artery disease
 Hypertension
 Diabetic patients must be considered as being at high risk of MI
 Induction of anaesthesia and tracheal intubation can lead to a
reduction in cardiac output
 Management
 Most cardiac and antihypertensive drugs should be continued
throughout the perioperative period except, aspirin, diuretics and
anticoagulants
 History to determine effort tolerance, clinical examination for
cardiac failure and an electrocardiogram in all patients.

23. Underlying Renal Complications of Diabetes
and Surgery
 Renal
 Renal dysfunction
 Intrinsic renal disease including glomerulosclerosis and
renal papillary necrosis enhance the risk of acute renal
failure perioperatively
 Proteinuria is an early manifestation
 Dialysis should optimally be done the day before surgery.
 Urinary infection
 Management
 Urea and electrolyte determination.
 Dipstix urinalysis for proteinuria

24. Underlying Nervous System Complications
of Diabetes and Surgery
 Nervous System
 Counter-regulatory response to hypoglycaemia
 Peripheral neuropathy with an increased susceptibility
to iatrogenic nerve injuries
 Cardiac Autonomic Neuropathy
 Management
 History of postural dizziness, post gustatory sweating,
nocturnal diarrhoea and impotence.
 Careful documentation of peripheral sensation

25. Underlying Immune Complications of Diabetes
and Surgery
 Immune and infectious risk
 Diabetics are susceptible to infection and have delayed wound
healing
 Hyperglycaemia
 facilitates proliferation of bacteria and fungi
 depresses the immune system management
 Proteolysis and decreased amino acid transport retards wound
healing.
 Loss of phagocytic function increases the risks of post-operative
infection
 Management
 Need very strict sterile techniques and need to assess risk/benefit
ratio for procedures e.g catheterisation

26. Underlying Gastrointestinal and
Ophthalmological Complications of Diabetes
and Surgery
 Gastrointestinal
 Gastroparesis
 Management
 History of early satiety and reflux
 H2 blocker and metoclopramide
 Ophthalmology
 Cataracts, glaucoma and retinopathy decrease visual acuity and
increase the unpleasantness of the perioperative period
 Management
 Increase the amount of explanation and reassurance to the patient.

27. Principles of Managing Diabetics During Surgery
 Diabetic management depends upon:
 the nature of the diabetes and its treatment (insulin-dependent or non-
insulin-dependent)
 the magnitude of the surgery contemplated, in particular duration of
fasting
 the time available for improving control of the diabetes preoperatively if
necessary
 Management of preoperative insulin therapy depends on baseline blood
glucose, level of diabetic control, severity of illness and the proposed
surgical procedure
 However, aims for all diabetic patients are:
 No excess mortality
 No increase in post-op complications
 Normal wound healing
 No increase in duration of hospitalisation
 No hypoglycaemia, hyperglycaemia or ketoacidosis

28. Pre-operative Assessment of Patient with Diabetes
 History : duration of diabetes, control & organ effects,
dietary intake, associated co-morbidities with medications,
h/o previous surgeries, anaesthesia and drug allergies.
 Physical Exam : signs & symptoms of autonomic
dysfunction, cardiac ds, renal ds, retinal involvement
• Lab Investigations : Fasting PG, PPPG, B.Urea, Creatinine,
Electrolytes, Urine Albumin/ Creatinine ratio, HbA1c (to
assess how well controlled diabetes is)
 Cardiac evaluation : Chest X Ray & Echocardiography,
TMT depending upon clinical situation, optimise blood
pressure

29. Glycemic Targets for Surgical Patient
 Too tight control of blood sugar to be avoided
 Non-critically ill patient : < 140 mg/dl preprandially &
<180mg/dl postprandially
 Critically ill patients : 110mg/dl preprandially &
< 180 mg/dl postprandially
 HbA1c should be 48-59 mg/dl or 6.5-7.5mmol/L in a well-
controlled diabetic patient

30. General Guidelines
Patients on OAD with good glyc control for minor surgery:
 can continue usual medications
 Metformin should be stopped 24-48 hrs prior to surgery &
restarted only after checking RFT post op.
 Long acting Sulfonylureas (SU) to be substituted with short acting
SU, 5 days prior to surgery to prevent hypoglycemia
 Patient need to be admitted on day of surgey
 Place first on morning operating list if possible
cont...

31. Indications of starting Insulin preoperatively :
 Poor glycemic control
 Infection
 Nil oral instructions
 Non healing wounds
 Other co-morbid conditions

32. Patients on OAD with poor glycemic control :
 Swich over to Insulin
 Admit 2 to 3 days prior to surgery
 Patients on insulin to be continued on insulin, may need
dose adjustment to achieve glycemic targets

33. Intraoperative Management
 Best to post surgery in morning (First on the OT list)
 Morning dose of OAD is omitted as patient will not have
break fast
 At the start of surgery IV insulin & glucose is given either
through separate lines or as a combined GIK (Glucose-
Insulin-Potassium infusion)
 GIK is simpler but any changes in dosage necessitates
change of entire infusion.
 Separate insulin and glucose infusion is better and needs
close blood sugar monitoring.
Cont...

34. Cont...
 Blood glucose should be monitored hourly during &
immediately after procedure & changes in infusion rate
are made as needed.
 Once patient is allowed to take orally, Subcutaneous
insulin is started
 IV Fluids During Surgery :
1. Dextrose saline or normal saline if BP is low or normal
2. If IVF restriction is advised 10% Dextrose instead of
5% Dextrose
3. Avoid Ringer Lactate solution

35. Management Protocols for Elective Surgery in
Patients with Diabetes
Before and
preoperative
Surgery
Post-operative
PATIENTS NOT ON INSULIN
Minor surgery and
good glycemic control
Replace any long-acting SU
admit day before Surgery
Operate in morning
omit breakfast and oral agents
avoid glucose containing infusions
monitor blood glucose 2- hourly
Monitor blood glucose restart oral
agents with first post op meal

36. Management Protocols for Elective Surgery in
Patients with Diabetes
Before and
preoperative
Surgery
Post-operative
PATIENTS NOT ON INSULIN
Major Surgery and/ or
poor glycemic control
Admit 2-3 days before surgery
stablize control with insulin
Operate in morning
Start IV insulin and glucose
Omit breakfast & insulin
Monitor blood glucose hourly
Monitor blood glucose
Transfer to SC insulin once oral
intake restarted. Return to oral
agents when control stable

37. Management Protocols for Elective Surgery in
Patients with Diabetes
Before and
preoperative
Surgery
Postoperative
PATIENTS TREATED ON INSULIN
Good/ poor control
Admit 2-3 days before surgery
Stablize control if necessary
Operate in morning
Start IV insulin and glucose
Omit breakfast & insulin
Monitor blood glucose hourly
Monitor blood glucose
Restart SC insulin before first
postoperative meal
discontinue iv insulin 30- 60 min later

38. 1 ml per hour
Intra-operative Insulin Infusion

39. Intra-operative Insulin Infusion

40. Adjusting Insulin Infusion rate
with hourly blood sugar levels
Blood Glucose (mg/dl) Insulin infusion rate
<80 Glucose at 5-10 gm/hr, recheck after 15 m
80 - 140 Decrease infusion by 0.4 U/ hr
141 - 180 No change
181 - 220 Increase by 0.4 U/hr
221 - 250 Increase by 0.6 U/hr
251 - 300 Increase by 0.8 U/hr
> 300 Increase by 1 U/hr

41. Post operative management
 Patients who need to continue fasting after surgery should
be maintained on IV Insulin and fluids until they are able
to eat and drink
 IV fluids during prolonged insulin infusion should include
saline and potassium supplimentation
 UK guidelines recommend use of dextrose/saline (0.45%
saline with 5% dextrose & 0.15% potassium chloride).
 When patient’s usual treatment has been reinstated, care
must be taken to continue to control the blood glucose ,
ideally b/w 4-10 mmol/L ( 70-180mg/dl).
 Patients normally controlled on tablets may require
temporary subcutaneous insulin treatment until the
increased stress of surgery, wound healing or infection has
resolved
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42. THANK YOU
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