25% diabetic patient need surgery. He or she may have surgical disease along with diabetes or diabetes may complicate to surgical conditions. So it is critical to manage diabetes during surgical events.

1. Diabetes and Surgery
DR. HRIDAY RANJAN ROY
Assistant Professor (Surgery)
Department of Surgery
Rangpur Medical College &
Hospital

2. Importance of controlling Diabetes in
Surgery
It is critical to control diabetes during surgery
(pre-, per- and postoperatively). The causes
are:
1. Tight control is needed to avoid hyper- or
hypoglycemia,
2. Patient need fasting (NPO) for operative
procedures,
3. So adjustment of glucose level control
become critical

3. Standard Protocol
I am going to present some evidence based
practice in which glucose level control
protocol is gold standard.

4. Preoperative glucose level
Should be maintained at:
Fasting <90mg/dl
Postprandial <180mg/dl
Hb1c <7%
Journal of Indian Medical association
2010 Jan; 108(1): 52-5

5. Peroperative and ICU
Glucose level must be maintained in between
140-180mg/dl.
(80-110mg/dl protocol has chance to develop
fatal hypoglycemia and 12.1% mortality)
Journal of Indian Medical association
2010 Jan; 108(1): 52-5

6. Sliding Scale
Use of Sliding scale insulin therapy during
operation is no more useful and should be
stopped.
JAMA 2009 Jan 14; 301(2)213-4

7. Why to control DM during Surgery
25% diabetic patient need surgery.
Hyperglycemia during surgery may produce:
1. Dehydration (Osmotic Diuresis)
2. Electrolyte imbalance
3. Impair wound healing
4. Increase infection rate
5. Chance to develop keto acidosis
6. Has detrimental effect on CVS and renal
function.
Archives of Internal Medicine
1999 Nov 8; 159: 2405-2411

8. Surgical trauma raise glucose level
• Operative trauma has chance to develop
hyperglycemia due to raised catecholamines
and glucagon, increase glucose production by
liver and decrease utilization by peripheral
tissues.
• In the other hand, fasting (for operative
purpose) along with insulin may produce
hypoglycemia which is more detrimental.
Archives of Internal Medicine
1999 Nov 8; 159: 2405-2411

9. Protocol of Control
Protocol for control of glucose level:
DM with diet= nothing needed
DM with Oral (metformin)= discontinue on
the day of surgery
DM with insulin= convert to intermediate
acting
Archives of Internal Medicine
1999 Nov 8; 159: 2405-2411

10. Protocol of Control (Cont..)
If morning fasting is needed for surgery, 1/3,
1/2, or 2/3 of usual insulin dose. If fasting
need to be continued (for surgery), 5gm
glucose/hour (1000 ml DA or DNS in 10 hours)
with usual insulin dose.
Archives of Internal Medicine
1999 Nov 8; 159: 2405-2411

11. Protocol of Control (Cont..)
I/V insulin protocol (regular soluble insulin):
Half life of IV insulin < 10 minutes. So
continuous or more frequent dose should be
administered.
Archives of Internal Medicine
1999 Nov 8; 159: 2405-2411

12. Protocol of Control (Cont..)
2 protocols:
1. Intermittent bolus technique= 10 U/2 hrs. Or
if blood glucose>11mmol/L= 5 U/ hour.
2. I/V continuous: 0.5 to 5 U with glucose.
Exactly 0.3 U / gm of glucose. This means
0.3X50= 15 U / 50gm (1000ml of DA or DNS).
Archives of Internal Medicine
1999 Nov 8; 159: 2405-2411

13. GKI protocol
GKI protocol (Glucose-Pottasium-Insulin):
Very important regim:
500ml 10% glucose (50gm) + 10 mmol
pottasium + 15 U insulin.
@100ml/hour= 1600 drops/ 60 min= 26
d/min). Insulin increment may be needed if
blood glucose > 180mg%.
Archives of Internal Medicine
1999 Nov 8; 159: 2405-2411

14. Crit Care Med 2007; 35 (9 suppl):
S503-S507
Peroperative control to 80-110gm% should
not be practiced as has chance to develop
detrimental hypoglycemia. Rather 140-180gm
% maintenance is safe. Hypo= <2.2 mmol/L or
<40mg%= 12.1% mortality.

15. Thank you All