Diabetic mellitus

1. ANAESTHESIA FOR PATIENTS
WITH DIABETES MELLITUS
Prof. Dr. Gautam Ratna Bajracharya
B.Sc.; M.B.B.S.; M.D
Department of Anaesthesiology and Critical Care
Kathmandu Medical College Public Limited,
Affiliated to Kathmandu University
Sinamangal, Kathmandu Nepal

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EPIDEMIOLOGY
DIABETES IN NEPAL - 2015
Total adult population (1000s)
(20-79 years)
15,750 Number of deaths in adults
due to diabetes
11,700
Prevalence of diabetes in adults
(20-79 years) (%)
3.3 Number of cases of
diabetes in adults that are
undiagnosed (1000s)
323.7
Total cases of adults (20-79 years)
with diabetes (1000s)
526.0

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Explanation
•In 2017, the prevalence of diabetes in Nepal was 4%.
•In 2021, the prevalence of diabetes in Nepal was 6.3%.
•The prevalence of diabetes in Nepal is expected to increase to 6.1% by
2045.
•The prevalence of diabetes in Nepal is expected to increase due to
•unhealthy diets,
•sedentary lifestyles, and
•genetic factors.
The prevalence of diabetes in Nepal is expected to increase due to
a lack of diabetes education and
limited adoption of behavioral changes.

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EPIDEMIOLOGY
• THURSDAY, Nov. 14, 2024 (HealthDay News) -- Fourteen percent of
the world's people -- more than 800 million -- now have diabetes, a
doubling of the global rate for the blood sugar disease since 1990,
new statistics show
• Nearly one-fifth of surgical patients have diabetes
• The prevalence of diabetes in surgical patients varies depending
on the study and population, but generally falls within a range
of 10-20%; meaning that around 10-20% of people undergoing
surgery are likely to have diabetes.
• One third of them are newly identified as having diabetes preoperatively.

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• The number of people with diabetes rose from 108
million in 1980 to 422 million in 2014. Prevalence has
been rising more rapidly in low- and middle-income
countries than in high-income countries.
• Diabetes is a major cause of blindness, kidney failure,
heart attacks, stroke and lower limb amputation.
• Between 2000 and 2019, there was a 3% increase in
diabetes mortality rates by age.
• In 2019, diabetes and kidney disease due to diabetes
caused an estimated 2 million deaths.

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• In 2022, 14% of adults aged 18 years
and older were living with diabetes, an
increase from 7% in 1990. More than
half (59%) of adults aged 30 years and
over living with diabetes were not
taking medication for their diabetes in
2022. Diabetes treatment coverage was
lowest in low- and middle-income
countries.

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• In 2021, diabetes was the direct cause
of 1.6 million deaths and 47% of all
deaths due to diabetes occurred before
the age of 70 years.
• Another 530 000 kidney disease deaths
were caused by diabetes, and
• high blood glucose causes around 11%
of cardiovascular deaths

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Symptoms of diabetes may occur suddenly. In
type 2 diabetes, the symptoms can be mild and
may take many years to be noticed.
Symptoms of diabetes include:
•feeling very thirsty
•needing to urinate more often than usual
•blurred vision
•feeling tired
•losing weight unintentionally

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INTRODUCTION
Diabetes mellitus is a group of metabolic
diseases characterized by hyperglycemia
resulting from defects in insulin secretion,
insulin action, or both.
(American Diabetic Association)

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CRITERIA FOR THE DIAGNOSIS OF DIABETES
HbA1C ≥6.5%.
OR
FPG ≥126 mg/dL (7.0 mmol/L). (no caloric intake for at least 8 h )
OR
2-h PG ≥200 mg/dL (11.1 mmol/L) during an OGTT.
OR
In a patient with classic symptoms of hyperglycemia , a random plasma glucose ≥200
mg/dL (11.1 mmol/L).
Diabetes Care January2015 vol. 38 no. Supplement 1 S8-S16

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What are the guidelines for diagnosis of diabetes
mellitus?
The diagnosis of diabetes can be established by
using
any of the following criteria.
a) Fasting plasma glucose 7.0mmol/l (126mg/dl)
≥
after
an overnight fast. This should be confirmed by
repeat test.

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Type 2 diabetes is diagnosed using blood tests that
measure blood sugar levels. The criteria for diagnosis
include:
•Fasting plasma glucose: A level of 126 mg/dL (7.0
mmol/L) or higher
•Random plasma glucose: A level of 200 mg/dL (11.1
mmol/L) or higher, especially if other symptoms are
present
•Glycated hemoglobin (A1C): A level of 6.5% or higher
on two separate tests
•2-hour post-load plasma glucose: A level of 200
mg/dL (11.1 mmol/L) or higher

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What are 10 warning signs of diabetes?
If you have any of the following diabetes
symptoms, see your doctor about getting your
blood sugar tested:
•Urinate (pee) a lot, often at night.
•Are very thirsty.
•Lose weight without trying.
•Are very hungry.
•Have blurry vision.
•Have numb or tingling hands or feet.
•Feel very tired.
•Have very dry skin.
May 14, 2024

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PREDIABETES
FPG 100 - 125 mg/dL ( 5.6 -6.9 mmol/L) (IFG)
OR
2-h PG in the 75-g OGTT (140 - 199 mg/dL )(7.8 - 11.0 mmol/L) (IGT)
OR
HBA1C 5.7–6.4%

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CLASSIFICATION
• Type 1 Diabetes
• Type 2 Diabetes
• Gestational Diabetes Mellitus (GDM)
• Other specific types
Genetic defects in β-cell function-MODY
Genetic defects in insulin action
Diseases of the exocrine pancreas- cystic fibrosis, hemochromatosis, pancreatitis
Endocrinopathies - Cushings syndrome, Acromegaly, Hyperthyroidism
Infections- CMV, Congenital Rubella
Drugs and chemicals- Pentamidine, Diazoxide

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TYPE 1 DM
• 5-10% of total diabetic population
• T Cell mediated autoimmune destruction of pancreatic beta cells.
• classical signs of diabetes occurs only when 80 – 90% of functional
capacity of beta cells have been lost.
• Destructive process is beta cell specific.
• 15% prevalence of other autoimmune diseases,
 Graves’ disease
 Hashimoto's thyroiditis
 Addison's disease
 Myasthenia gravis.
Strong HLA associations-DQA and DQB genes

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TYPE 2 DM
• Accounts for 90-95% of total diabetic population
• Combination of:
-Insulin resistance
-Relative insulin deficiency

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Pathological changes in diabetes

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Pathological changes in diabetes
1 .CNS
Transient ischaemic attack
Stroke
2.Ocular
Diabetic retinopathy
proliferative and non proliferative DR
3.CVS
Angina
Myocardial infarction
Heart failure
4.Renal
Microalbuminuria
Proteinuria
ESRD
5 Autonomic neuropathy
6.Erectile dysfunction
7. Autonomic dysfunction
8. Stiff joint syndrome

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Diabetic nephropathy
• Diabetic Nephropathy is the commonest cause of end-stage renal failure
(ESRF) in the Western world.
• Clinical course : microalbuminuria through proteinuria, azotaemia
and culminating in ESRF.
• Before the onset of overt proteinuria, renal functional changes include
renal hyperfiltration, hyperperfusion, and increasing capillary permeability
to macromolecules.
• Pathological hallmark of diabetic nephropathy :Basement-membrane
thickening and mesangial expansion

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Diabetic autonomic neuropathy
• Diabetic autonomic neuropathy (DAN) is a serious and common complication
of diabetes.
• DAN is among the least recognized and understood complications of diabetes
despite its significant negative impact on survival and quality of
life in people with diabetes .
• DAN can involve the entire autonomic nervous system (ANS). ANS
vasomotor, visceromotor, and sensory fibers innervate every organ.
• Hypotheses concerning the multiple etiologies of diabetic neuropathy include a
metabolic insult to nerve fibers, neurovascular insufficiency, autoimmune
damage, and neurohormonal growth factor deficiency .

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Manifestations of DAN
• Cardiovascular
● Resting tachycardia
● Exercise intolerance
● Orthostatic hypotension
● Silent myocardial ischemia
GI
● Esophageal dysmotility
● Gastroparesis diabeticorum
● Constipation / diarrhoea
● Fecal incontinence
Genitourinary
● Neurogenic bladder (diabetic cystopathy)
● Erectile dysfunction
● Retrograde ejaculation
● Female sexual dysfunction (e.g., loss of
vaginal lubrication)
• Sudomotor
● Anhidrosis
● Heat intolerance
● Gustatory sweating
● Dry skin
Pupillary
● Pupillomotor function impairment
(e.g., decreased diameter of darkadapted
pupil)
● Argyll-Robertson pupil
Metabolic
● Hypoglycemia unawareness
● Hypoglycemia-associated autonomic
failure

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Diabetic retinopathy
• The prevalence of retinopathy is strongly related to the duration of
diabetes.
• After 20 years of diabetes, nearly all patients with type 1 diabetes and 60%
of patients with type 2 diabetes have some degree of retinopathy.

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Stiff joint syndrome
• Significant risk during airway management.
• Affects atlantooccipital, temporo-mandibular and cervical spine.
• Shiny and waxy skin.
• Related to non enzymatic glycosylation of collagen and its deposition in
joints.

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COMPLICATIONS

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Hypoglycemia
CAUSES:
 Over dose of insulin
 Missed diet
 Heavy exercise
 Alcohol
 Gastoparesis
MANAGEMENT:
1.Glucose (15–20 g) is the preferred treatment for the conscious individual
with hypoglycemia.
2. If unconscious, 50ml of 50% glucose (or any glucose solution available)
given intravenously and repeated as necessary.
3. 1mg of glucagon IM

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Diabetic ketoacidosis
PRECIPITATING FACTORS:
– Infection, particularly pneumonia & urinary tract infection
– Inadequate insulin treatment or noncompliance
– New-onset diabetes
– Cardiovascular disease, particularly myocardial infarction
– Atypical antipsychotic agents
– Corticosteroids
CRITERIA:
1. Blood glucose > 200 mg/dL
2. Blood pH < 7.3
3. Blood bicarbonate < 15 mEq/L
4. hyperketonemia(>3mmol/l) and ketonuria (>2 on standard urine
sticks)

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HYPERGLYCEMIC HYPEROSMOLAR COMA
• Occurs in Type 2 DM
• Life threatening medical emergency
• High mortality rate
• Enough insulin is secreted to prevent ketosis, but not enough to prevent
hyperglycemia
• High blood sugar causes an extreme diuresis with severe electrolyte and
fluid loss.
CRITERIA
1. Serum Glucose 600 mg/dl
2. Hyperosmolarity(s.osm>320mosm/kg)
3. Arterial pH > 7.3
4. Serum Bicarbonate > 15 mEq/L

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ANAESTHETIC CONSIDERATIONS

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PRE-OPERATIVE MANAGEMENT
COMPONENTS:
1)Pre-operative assessment:
-History
-Clinical examinations &
- Investigations
2)Pre-operative Preparations
GOALS:
Avoidance of clinically
significant hypoglycemia
Maintenance of electrolyte and
fluid balance
Prevention of ketoacidosis
Achievement of specific
glycemic targets

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PRE-OPERATIVE ASSESSMENT
1. Adequacy of Blood Sugar Control
2. Nephropathy
3. Autonomic neuropathy
4. Peripheral neuropathy
5. Retinopathy
6. Stiff joint syndrome
7. Electrolyte & metabolic derangement

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1.ADEQUACY OF BLOOD SUGAR CONTROL
History and Examination Investigation
-Hyper/Hypoglycemic episodes
-Medication
-Compliance
- Blood sugar (fasting, PP)
- GTT (when PP>200mg/dl)
-Glycosylated Hb (HbA1
c)

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1.ADEQUACY OF BLOOD SUGAR CONTROL:
RECOMMENDATIONS
SAMBA GUIDELINES,2010
• It may be acceptable to proceed with surgery in patients with preoperative
hyperglycemia but with adequate long term glycemic control.
• Management of diabetes should ideally include a combination of a target HbA1c
<7%(normal 4%–7%), a preprandial blood glucose level of 90 to 130 mg/dL and a
peak postprandial blood glucose level of <180 mg/dL.
• Chronically elevated blood glucose levels should not be decreased acutely in the
perioperative period.
AUSTRALIAN DIABETES SOCIETY,2013
• Postpone elective surgery if possible if glycaemic control is poor (HbA1c ≥ 9%).
• BGL should be kept between 5 – 10mmol/l during the peri-operative period.

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2.NEPHROPATHY
History and
Examination
Investigation Intra-op concerns
- H/O swelling of face
and body
- Hypertension and its
medication
-Urinary Protein
(esp.Microalbumin)
-B.Urea
-S. Creatinine
-S.Electrolytes
-Adequate hydration
should be ensured to
prevent postoperative
renal dysfunction.
-Nephrotoxic drugs
should be avoided.

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4.AUTONOMIC NEUROPATHY
History and Examination Anesthetic implications
1. Gastroparesis
a)Early satiety
b)Vomiting
c)Abdominal distension
2. Lack of sweating
3.Orthostatic hypotension
4.Bladder atony and urinary retention
5.Impotence
6. Resting tachycardia & Palpitation
1. Aspiration during induction and
postoperative period
2. Intraoperative and postoperative
cardiorespiratory arrest
3. Exaggerated pressor response to tracheal
intubation
4. Profound hypotension at induction
5. Intraoperative hypothermia
6. Impaired response to hypercapnia or
hypoxemia
7. Increased risk of urinary retention and
hypoxic episodes.

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5.PERIPHERAL NEUROPATHY
HISTORY AND EXAMINATION INTRA-OP CONCERN
-Any painful sensory neuropathies
-Mononeuritis multiplex
-Glove & stocking type
neuropathy
-Proper patient positioning
-Documentation of
pre-existing neuropathy
essential if regional
techniques are planned.

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5.RETINOPATHY
History and
Examination
Investigation Intra-op concerns
-Vision
deterioration
-Ophthalmologic
examination
-Homology exists between retinal &
cerebral vasculature.
-Thus indicates impairment of
microvascular circulation in the brain
as well.
-Important in determining individual
risks of cerebrovascular diseases,
such as vascular dementia and
stroke.

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6.STIFF JOINT SYNDROME
History and Examination Investigation Intra-op concerns
- Stiffness in hand joints
-Inability to approximate
the palmar surfaces of
phalangeal joints i.e.
“Prayer Sign”
- Tight-waxy skin
-X-ray cervical
spine to delineate
limited
Atlanto-axial
extension.
-Difficult
laryngoscopy and
intubation

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PRE-OP GYLCEMIC CONTROL STRATEGY
 Patients with well controlled diabetes by diet alone require no
special preoperative intervention for diabetes.
 Well-controlled type 2 diabetics do not require insulin for minor
surgery.
 Poorly controlled type 2 diabetics and all type 1 diabetics require
insulin even for minor surgery.
 All diabetics having major surgery need insulin.

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PREOPERATIVE PREPARATIONS
1) MANAGEMENT ORAL HYPOGLYCEMIC AGENTS
2) MANAGEMENT OF INSULIN IN PATIENTS ALREADY ON
INSULIN
3) PRE-OP GLYCEMIC CONTROL STATEGY
1) -Minor Vs Major surgery
2) -Well controlled Vs Poorly controlled Diabetes
3) -Type-1 Vs Type-2 DM
4) PRE-OP INSULIN INFUSION REGIMENS
5) PRE-MEDICATION AND NIL PER ORAL DURATION

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Oral hypoglycemic agents
DRUG CLASS MECHANISM OF ACTION HALF
LIFE(Hrs.)
ADVERSE EFFECTS
A)BIGUANIDES
Eg. Metformin
-Decrease hepatic gluconeogenisis
-Increase insulin sensitivity.
6-18 Diarrhea, nausea, vomiting, lactic
acidosis
B) SULPHONYLUREAS
Eg.Glipizide
Glimepiride
Gliburide
-Stimulate insulin secretion
-Decrease insulin resistance
2-10 Hypoglycemia
GI disturbance
C)THIAZOLIDINDIONES
Eg.Pioglitazone
Rosiglitazone
-Decrease insulin resistance
-Decrease hepatic glucose
Production.
3-8 Fluid retention
CCF
Hepatotoxicity
D)ALPHA-GLUCOSIDASE
INHIBITORS
Eg. Acarbose
-Reduce the intestinal absorption of
ingested glucose
2–4 Gastrointestinal irritation, flatus
E) Meglitinides
Eg.Repaglinide
Nateglinide
-Stimulate pancreatic insulin
secretion.
1 Hypoglycemia, but less common in
comparison with sulphonylureas
F) Dipeptidyl peptidase-4
inhibitors
Sitagliptin
Saxagliptin
-Reduces breakdown of
gastrointestinal hormone-incretins
-Enhance insulin secretion &
decrease glucagon
8-14 Infection

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MANAGEMENT OF OHAs
DRUG CLASS RECOMMENDATIONS RATIONALE
SULPHONYLUREAS: •Hold the morning dose on
the day of surgery except
chlorpropamide which
should be held 2-3 days prior
to surgery.
-May induce hypoglycemia in
patients who are placed on NPO
-Block myocardial K-ATP
channels, resulting in ischemia-
and anesthetic-induced
preconditioning
BIGUANIDES: •Hold 1 to 2 days before
planned surgery especially in
sick patients and those
undergoing procedures that
increase the risks for renal
hypoperfusion, tissue
hypoxia,
and lactate accumulation.
-Can induce lactic acidosis if
kidney function declines
THIAZOLIDINEDIONES: •Hold the morning dose on
the day of surgery
-May cause fluid retention that
can complicate the postoperative
period

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TREATMENT OPTIONS-
INSULIN THERAPY

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MANAGEMENT OF INSULIN IN PATIENTS
ALREADY ON INSULIN
BASAL INSULIN -Longer acting insulins,e.g. glargine and NPH,
which provide a constant supply of
“background” insulin, regardless of meals.
-All patients with Type 1 diabetes require this.
-And many with Type 2 diabetes need this,
especially in the perioperative period.
PRANDIAL INSULIN -The fixed dose of rapid acting insulin,e.g.
lispro, aspart, or regular, which is given before
a meal to mimic the body’s normal response to
a caloric load.
CORRECTION INSULIN
(REPLACES THE OLDER TERM “SLIDING
SCALE”)
-The variable amount of insulin given in
addition
to the prandial and/or basal insulin to correct
hyperglycemia.
Basic terminologies:

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INSULIN INFUSION REGIMEN-1
(GIK system or the Alberti-Thomas regimen or WATTS regimen)
• No infusion pump available

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INSULIN INFUSION REGIMEN-2

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PRE-MEDICATION AND NIL PER ORAL
DURATION
• No modifications in standard practices except
when gastroparesis is suspected
• Patients with gastroparesis should be:
Premedicated with prokinetic drug

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INTRA-OPERATIVE MANAGEMENT
A. Choice of Intra-op fluid
B. Management of Anaesthesia
C. Patient positioning
D. Monitoring

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CHOICE OF INTRA-OP FLUID
• Ideal crystalloid solution for iv infusion in diabetic patients
undergoing surgery should have the following properties:
1. sufficient glucose to minimise catabolism and permit insulin infusion
2. contain potassium and be compliant with safety recommendations
3. isotonicity
4. should not result in hyperchloraemic acidosis
• At present, the best option for diabetic patients receiving an insulin infusion in
the peri-operative period is 5% glucose in 0.45% sodium chloride solution with
potassium 20 mmol.l−1
• Ringer’s lactate is best avoided as lactate is gluconeogenic and is rapidly
converted to glucose especially in a starved and catabolic state like DM.
• However, recent studies suggest that the maximum increase in glucose
concentration with 1 L of Hartmann’s solution would be about 1 mmol/L (about
18 mg/dl).
• Hartmann’s solution is unlikely to adversely affect glycemic control.

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MANAGEMENT OF ANAESTHESIA
• No contraindications to standard anesthetic induction & inhalational agents.
• Benzodiazepines in high doses reduce sympathetic stimulation and decrease
glycemic response to surgery
• High dose opiate techniques produce metabolic,hormonal as well as hemodynamic
stability and thus abolishes hyperglycemia.
• Careful titration of inducing agents with adequate preloading to avoid hypotension
due to autonomic neuropathy .
• Difficult intubation with aggravated hemodynamic response should be anticipated
in long standing diabetics.
• Halothane,enflurane and isoflurane,in vitro,inhibit insulin response to glucose in
reversible and dose dependent manner
• Studies have shown recovery from the nondepolarizing neuromuscular agent,
vecuronium, is delayed in diabetic patients compared with nondiabetic patients.
• Etomidate blocks cortisol synthesis and hence blunts the hyperglycemic response to
surgery

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PATIENT POSITIONING
• Proper positioning of the patient is very important:
1. To avoid pressure sores
2. To avoid sudden drop in blood pressure associated with rapid
changes in position.

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Blood glucose monitoring
• stable diabetic patients undergoing short (<2hrs) procedures : check
blood glucose on admission, before operation, and on discharge.
• patients receiving intraoperative SC insulin : check levels every 1–2hrs .
• patients having extensive surgical procedures, or patients on insulin
infusions, ADA recommends glucose monitoring as frequently as every 30
min.
• Intraoperative glycemic target :Intraoperative IIT is currently not
recommended because of conflicting data and the risk of hypoglycemia.
• Treatment initiated with an insulin infusion at blood glucose no greater
than 10 mmol/l (180 mg dl−1
)and maintained at a target BG of 7.7–10
mmol/l (140–180 mg/dl). Level below 110mg/dl is not recommended.

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POST-OPERATIVE MANAGEMENT
• The Diabetes UK Position Statement and Care Recommendations :
maintain blood glucose in the range of 6–10 mmol/l (108–180 mg /dl) if
safely achievable.
• The correction can be achieved using SC insulin or i.v.insulin.
• Blood glucose levels must be assessed at least hourly, or more frequently
if readings are outside the target range
• Insulin-glucose infusion should be continued until patient can tolerate
adequate oral intake.

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• Nausea and vomiting should be prevented, and if present, should
be treated vigorously.
• Nonsteroidal anti-inflammatory drugs should be used with
caution in patients with renal dysfunction.
• Judicious use of antibiotics and better wound care and
postoperative glycemic control can prevent postoperative
infection

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REGIONAL ANAESTHESIA
• Useful because:
i. Avoids starvation (before and after surgery),
ii. Avoids hormonal and metabolic changes that occur during
general anesthesia and
iii. Facilitates early mobilization
iv. Facilitates minimal interruption of the normal daily routine of
diet and treatment
v. Early detection in case of hypoglycemia

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REGIONAL ANAESTHESIA
ANAESTHETIC ISSUES:
• Local anesthetic requirements are lower.
• Autonomic neuropathy may lead to immediate,profound
refractory hypotension. Rx:Ephedrine(6mg boluses) when the
systolic pressure falls to 25% below normal.
• The risk of nerve injury is higher in diabetic patients.
• Adding adrenaline to anesthetic solution increases risk of
ischemia and edematous nerve injury.
• Increased risk of infection and vascular damage, epidural
abscess, etc.

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MANAGEMENT OF INSULIN IN PATIENTS
ALREADY ON INSULIN
PERIOPERATIVE GUIDELINES
• Stop long acting insulin preparations at least 24 hrs prior to surgery.
• If on short acting/regular insulin,continue normal dose till the pre-
dinner dose the night before the day of surgery.
• Start sliding scale regular insulin(S/C) 24 hrs prior to
surgery,according to RBS every 6hrly.
0 - 7.1 mmol/L:NO INSULIN
7.1 - 10.1 mmol/L:4 UNITS REGULAR INSULIN
10.2 - 15.1 mmol/L:6 UNITS REGULAR INSULIN
15.2 - 20.0 mmol/L:8 UNITS REGULAR INSULIN
>20.0 mmol/L:10 UNITS REGULAR INSULIN

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Conclusion
• Diabetes mellitus has an effect on various organ
systems of the body, which should be properly
evaluated and managed before surgery for better
outcome
• Perioperative glycemic control should aim at preventing
hypoglycemia, hyperglycemia, ketosis, dehydration and
maintaining normal electrolyte balance
• Various acute complications like hypoglycemia,
ketoacidosis and hyperosmolar coma should be
identified and managed timely.

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• REFERENCES:
1. Stoelting’s Anesthesia and Co-existing disease – 5th
edition
2. Miller’s Anaesthesia-8th
edition
3. Morgan’s Clinical Anaesthesiology-5th
edition
4. UpToDate 19.3
5. Davidson’s Principle and practice of Medicine- 22nd
edition