The document provides information about diabetes mellitus (DM) and its management in the perioperative period. It begins with objectives of defining DM and describing its types, pathophysiology, clinical features, and anesthetic management. It then defines DM as a disease marked by high blood sugar. It discusses the effects of surgical stress and anesthesia on blood glucose levels in DM patients and the need for careful glycemic control in the perioperative period to reduce morbidity and mortality. It also provides details on the pancreas, different types of DM, risk factors, normal glucose metabolism, criteria for DM diagnosis, and preoperative evaluation of DM patients.

1. 12/2/2019 DM 1

2. • Objectives
• Definition of DM
• Introductions
• Types of DM
• Pathophysiology of DM
• Clinical features of DM
• Pre operative evaluation
• Anesthetic management of DM
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3. OBJECTIVES
• Upon completion of the course, students will be able to:
• Define diabetes mellitus
• List types of DM
• Describe the causes of diabetes mellitus
• Explain signs and symptoms of DM
• Explain the preoperative evaluation, preparation and management of DM patients
• Describe the complications of DM
• Manage DM patients intra operatively
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4. Definition of Diabetes Mellitus
• Diabetes Mellitus is a disease marked by high levels of sugar in the
blood.
• Mellitus is Latin for “sweet as honey”.
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5. INTRODUCTION
• The effects of surgical stress and anesthesia have unique effects on
blood glucose levels, which should be taken into consideration to
maintain optimum glycemic control.
• Interestingly, the literature still does not report a consensus
perioperative glucose management strategy for diabetic patients.
• Overall, through careful glycemic management in perioperative
period, we may reduce morbidity and mortality and improve surgical
outcomes.
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6. CONT…
• “A metabolic disorder of multiple aetiology characterized by chronic
hyperglycaemia with disturbances of carbohydrate, fat and protein
metabolism resulting from defects in insulin secretion, insulin action,
or both”
WHO
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7. The Pancreas
• The pancreas is an elongated, tapered gland that is located behind the
stomach and secretes digestive enzymes and the hormones insulin and
glucagon.
• The Pancreas secretes insulin and Glucagon directly into the blood
stream.
• It also secretes digestive enzymes into the pancreatic duct, which joins
the common bile duct from the liver and drains into the small intestine.
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8. Glucagon (α alpha cells)
• Glucagon is produced in the α cells and is released when the glucose
level in the blood is low.
• The liver then convert stored glycogen into glucose and release it into
the bloodstream.
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9. Insulin (β Beta cells)
• Beta Cells within the Islets of Langerhans produce insulin which is
needed to metabolize glucose within the body.
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10. Insulin & Glucagon
• Insulin and Glucagon have opposite effects on liver and other tissues
for controlling blood-glucose levels.
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11. Etiology
• Etiology of Type 1 Diabetes
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12. 12/2/2019 DM 12

13. Etiology of Type 2 Diabetes
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14. 12/2/2019 DM 14

15. 12/2/2019 DM 15

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17. 12/2/2019 DM 17

18. DIABETES MELLITUS
• Normal glucose physiology demonstrates a balance b/n glucose
utilization and endogenous production or dietary delivery.
• The liver is the primary source of endogenous glucose production via
glycogenolysis and gluconeogenesis.
• Following a meal, plasma glucose increases, which stimulates an
increase in plasma insulin (maximum insulin level is reached within
30 minutes) promoting glucose utilization.
• Late in the postprandial period (i.e., 2–4 hours after eating), when
glucose utilization exceeds glucose production, the plasma glucose
concentration decreases to below the fasting level before returning to
preprandial values.
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19. CONT…
• A transition from exogenous glucose delivery to endogenous
production then becomes necessary to maintain a normal plasma
glucose level.
• During the postabsorptive phase (i.e., 4–8 hours after eating) plasma
glucose remains relatively stable with production and utilization rates
being equal.
• At this time, 75% of glucose production results from hepatic
glycogenolysis and 25% from hepatic gluconeogenesis.
• Approximately 70% to 80% of glucose released by the liver is
metabolized by insulin-insensitive tissues such as the brain,
gastrointestinal tract, and red blood cells.
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20. CONT…
• During this time, diminished insulin secretion is fundamental to the maintenance of
a normal plasma glucose concentration.
• Hyperglycemia-producing hormones (glucagon, epinephrine, growth hormone,
cortisol) constitute the glucose counter regulatory system and support glucose
production.
• Glucagon plays a primary role by stimulating glycogenolysis, gluconeogenesis, and
inhibiting glycolysis.
• Epinephrine predominates when glucagon secretion is deficient.
• Neural glucoregulatory factors (i.e., norepinephrine) and glucose autoregulation
also support glucose production
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21. CONT…
• Humans require insulin for survival.
• DM results from an inadequate supply of insulin and an inadequate
tissue response to insulin, yielding increased circulating glucose levels
with eventual microvascular and macrovascular complications.
• Type 1 diabetes is caused by an autoimmune destruction of beta cells
within pancreatic islets resulting in complete absence or barely
negligible circulating insulin levels.
• Type 2 diabetes is not immune mediated and results from a relative
deficiency of insulin coupled with an insulin receptor defect or
defect(s) in its postreceptor intracellular signaling pathways.
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22. Risk Factor which predispose to Diabetes
• A parent, brother, or sister with diabetes
• Obesity
• Age greater than 45 years
• Some ethnic groups
• Gestational diabetes or delivering a baby weighing more than 9
pounds
• High blood pressure
• High blood cholesterol level
• Not getting enough exercise
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23. Normal Metabolism of Glucose
• Food is turned into sugar, called
glucose.
• Glucose is carried to the cells via
the blood stream.
• Glucose is required by all cells
for energy.
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24. Normal Metabolism of Glucose
For Glucose to enter the cell: - –
the cell should have enough
receptors.
 insulin is needed to ‘unlock the
receptors’.
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25. 12/2/2019 DM 25

26. CONT…
• Normally blood glucose is 4 to 8mmol/l.
• They are higher after meals and usually lowest in the morning.
• Fasting blood glucose of below 6mmol/l is normal.
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27. 12/2/2019 DM 27

28. TYPE 2 DIABETES
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29. Symptoms of Type 1 Diabetes
• Increased thirst
• Increased urination
• Weight loss in spite of increased appetite
• Fatigue
• Nausea
• Vomiting
• Coma
• Patients with type 1DM usually develop
symptoms over a short period of time, and
the condition is often diagnosed in an
emergency setting.
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30. Symptoms of Type 2 Diabetes
• Slower onset:
• Increased thirst
• Increased urination
• Increased appetite
• Fatigue
• Blurred vision
• Slow-healing infections
• Impotence in men
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31. CRITERIA FOR DIAGNOSIS OF DIABETES
• 1. Symtoms of diabetes plus random plasma glucose level >200
mg/dL (11.1 mmol/L)
• 2. Hemoglobin A1C ≥ 6.5 %
• 3. Fasting plasma glucose level ≥ 126 mg/dL (7.0 mmol/L)
• 4. Two hour plasma glucose > 200 mg/dL (11.1 mmol/L) during an
oral glucose tolerance test
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32. THE METABOLIC RESPONSE TO SURGERY AND
THE EFFECT OF DIABETES
• Metabolic effects of starvation:
• 1. Period of starvation induces a catabolic state.
• 2. It will stimulate secretion of counter-regulatory hormones .
• 3. It can be attenuated in patients with diabetes by infusion of insulin and glucose
(approximately 180g/day).
• Metabolic effects of major surgery.
• It causes neuroendocrine stress response with release of counter- regulatory
hormones (epinephrine, glucagon, cortisol and growth hormone).
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33. CONT…
Hypoglycemia – exacerbate the catabolic effect of surgery
These neuro hormonal changes result in metabolic abnormalities
including:
 Increased insulin resistance.
 decreased peripheral glucose utilization.
 impaired insulin secretion.
increased lipolysis .
protein catabolism, leading to
hyperglycemia and even ketosis in some cases…
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34. Metabolic consequence of surgical stress and anesthesia
• During the fasting state , normal subjects maintain plasma glucose levels b/n 60-
100mg/dl.
• The stress of surgery and anesthesia alters the finally regulated balance b/n hepatic
glucose production and glucose utilization in peripheral tissues.
• An increase in the secretion of counter regulatory hormones (catecholamine's, cortisol,
glucagon, and growth hormones) occurs, causing excessive release of inflammatory
cytokines including tumor necrosis factor-alpha, interlukin-6 and intterlukin-1beta.
• Cortisol increases hepatic glucose production, stimulates protein catabolism and
promotes gluconeogenesis, resulting in elevated blood glucose levels.
• Surging catecholamine's increases glucagon secretion and inhibit insulin release by
pancreatic beta cells.
• Additionally , the increase in stress hormones leads to enhanced lipolysis and high free
fatty acids (FFA) concentrations.
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35. PRE-OPERATIVE EVALUATION
Determine the type of diabetes and its management.
Ensure that the patient’s diabetes is well controlled.
 Review of medications.
 Ensure that the patient is capable of managing their diabetes after
discharge from hospital.
 Consider the presence of complications of diabetes that might be
adversely affected by or that might adversely impact upon the
outcome of the proposed procedure.
 Identify high-risk patients requiring critical care management.
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36. PRE-0PERATIVE EVALUATION
To Assess History/Examination Investigation
1. Blood Sugar Control Hypo/Hyperglycemic
episodes,
Hospitalization,
Medical compliance
BS- F & PP
HbA1C
2. Nephropathy H/O- HTN, Swelling over body,
Recurrent UTI.
Urine R/M (to exclude
Albuminuria and UTI) RFT
3. Cardiac Status H/O- Angina/ MI , Swelling of
feet, Exercise intolerance
ECG, CXR, ECHO,
(ECG-less predictive )
4. PVD H/O- Intermittent Claudication,
Blanching of feet, Non healing ulcer
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37. CONTD….
Patient is unable to approximate
the palmar surface of phalangeal
joints despite of maximal effort.
• Degree of inter-phalyngeal joint
involvement can also be assessed by
scoring the ink impressionmade by
the palm of dominant hand.
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38. Diabetic autonomic neuropathy
• Diabetic autonomic neuropathy can affect any part of the autonomic nervous system.
• Autonomic disturbances can be subclinical or clinical, with the former demonstrating
abnormalities on quantitative function tests and the latter presenting with clinical signs
and symptoms.
• Subclinical DAN can occur within a year or two after diagnosis, while clinical DAN
does not develop for many years and depends on the duration of diabetes and the
degree of metabolic control.
• Symptomatic autonomic neuropathy, excluding impotence, is rare and present in less
than 5% of diabetics.
• The pathogenesis is not completely understood and may involve metabolic,
microvascular, and/or autonomic etiologies.
• Intensive glycemic control is critical in preventing its onset and slowing its
progression.
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39. DAN…
• Cardiovascular autonomic neuropathy is a common type of DAN and is characterized
by abnormalities in HR control and central/peripheral vascular dynamics.
• A resting tachycardia and a loss of HR variability during deep breathing are early signs.
• A HR that fails to respond to exercise is indicative of significant cardiac denervation.
• Limited exercise tolerance results from impaired sympathetic and parasympathetic
responses responsible for cardiac output and peripheral blood flow.
• The heart may demonstrate systolic and diastolic dysfunction with a reduced ejection
fraction.
• Dysrhythmias may be responsible for an episode of sudden death.
• Patients with coronary artery disease may be asymptomatic during ischemic events.
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40. DAN…
• In its mildest form, patients demonstrate a resting tachycardia, and in the advance
stages, severe orthostatic hypotension (>30 mm Hg with standing) is present.
• These changes result from damaged vasoconstrictor fibers, impaired baroreceptor
function, and ineffective cardiovascular reactivity.
• The presence of cardiovascular autonomic neuropathy is demonstrated by testing
cardiovascular reflexes and measuring a patient’s resting HR, HR variability,
response to a Valsalva maneuver, orthostatic changes in HR and systolic pressure,
diastolic BP response to sustained exercise, and the QT interval.
• In addition to cardiovascular effects, patients with DAN may demonstrate
impaired respiratory reflexes and impaired ventilatory responses to hypoxia and
hypercapnia.
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41. CLINICAL SIGNS OF DIABETIC AUTONOMIC
NEUROPATHY
• Hypertension
• Painless MI
• Orthostatic hypotension
• Lack of HR variability
• Reduced HR response to atropine & propanolol
• Resting tachycardia
• Early satiety
• Nerugenic bladder
• Lack of sweating
• Impotence
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42. TESTS FOR DIABETIC AUTONOMIC NEUROPATHY
(DAN)
• Early stage: abnormality of HR response during deep breathing
• Intermediate stage: abnormality of Valsalva response
• Late stage: presence of postural hypotension
• The test are valid marker of DAN if following factors ruled out.
• 1. End organ failure
• 2. Concomitant illness
• 3. Drugs: antidepressants, antihistamines, diuretics, vasodilators,
sympathetic blockers, vagolytics.
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43. TEST FOR PARASYMPATHETIC CONTROL
• TEST FOR AUTONOMIC NEUROPATHY
• Heart rate variability (HRV) in response to:
• Deep breathing
• Standing
• Valsalva maneuver
• BP response to:
• 1.Standing or passive tilting
• 2.Sustained hand grip
• 3.Valsalva maneuver
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44. CONT…
DEEP BREATHING:
Respiratory sinus arrhythmia is a normal phenomenon due to vagal
input to sinus node during expiration causing cardio-deceleration
The patient lies quietly and breathes deeply at a rate of 6 breaths/min
(a rate that produces maximum variation in HR) while a heart monitor
records the difference b/n the maximum and minimum HR.
Normal variability: >15beats/min
Abnormal variability: <10beats/min
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45. CONT…
STANDING:
This test evaluates the cardiovascular response elicited by a change from a
horizontal to a vertical position.
 In healthy subjects,
Standing rapid increase in heart rate that is maximal at approximately
the 15th beat relative bradycardia that is maximal at approximately the
30th beat after standing.
 The patient is connected to an ECG monitor while lying down and then
made to stand to a full up right position.
 ECG tracings are used to determine the 30:15 ratio, calculated as the ratio
of the longest R-R interval (found at about beat 30) to the shortest R-R
interval (found at about beat15).
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46. CONT…
• VALSALVA MANEUVER:
• supine patient, connected to an ECG monitor
• forcibly exhales into the mouthpiece of a manometer, exerting a
pressure of 40mmHg, for 15 seconds with an open glottis
• sudden transient increase in intra-thoracic and intra-abdominal
pressures, with a characteristic hemodynamic response.
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47. CONT…
• The response has four phases and in healthy individuals can be
observed as follows:
• Phase I: Transient rise in BP and a fall in HR
• Phase II: Early fall in BP with a subsequent recovery of BP later in
the phase, accompanied by an increase in HR.
• Phase III: BP falls and heart rate increases with cessation of
expiration.
• Phase IV: BP increases above the baseline value(overshoot)
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48. CONT…
• The Valsalva Ratio is determined from the ECG tracings by calculating the ratio
of the longest R-R interval after the maneuver (reflecting the bradycardic response
to blood pressure overshoot) to the shortest R-R interval during or shortly after the
maneuver (reflecting tachycardia as a result of strain).
• Ratio < 1.2 is abnormal
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49. GENERAL PRINCIPLES
• Diabetes should be well controlled prior to elective surgery.
• Avoid insulin deficiency, and anticipate increased insulin requirements.
• The patient’s diabetes care provider should be involved in the management of
their patient’s diabetes peri-operatively.
• Patients must be given clear written instructions concerning the management of their
diabetes both pre- and post-operatively (including medication adjustments) prior to
surgery.
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50. CONT…
• Patients must not drive themselves to the hospital on the day of the procedure.
• Patients with diabetes should be on the morning list, preferably first on the list.
• These guidelines may need to be individually modified depending on the
patient’s circumstance.
• Patients should be well hydrated before the procedure.
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51. GOALS
• To maintain glycemic control.
• To prevent further deterioration of pre-existing end organ damage and minimize
the metabolic consequence of starvation and surgical stress.
• To shift patient soon on pre-operative glycemic control drugs and prevention of
PONV.
To prevent complication.
Greater concern for aseptic precaution.
Postoperative pain management.
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52. GLYCEMIC CONTROL
• Postpone elective surgery if possible if glycemic control is poor (HbA1c ≥ 9%).
• For major surgery, if serum glucose is >270 mg/dl preoperatively, surgery should be
delayed while rapid control is achieved with IV insulin.
• If serum glucose is >400 mg/dl , the surgery should be postponed and metabolic state
restabilized.
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53. CONT…
• BGL should be kept between 5 – 10mmol/l (90-180mg/dl) during the
perioperative period .
• For critically ill patients who require admission to the intensive care unit
post-operatively, a “tighter” BGL target (e.g 4.4-6.1 mmol/L) may not convey
any greater benefit.
• Hypoglycemia must be avoided.
• All patients with diabetes treated with insulin should be managed in the
same way, irrespective of whether they have type 1 or type 2 diabetes mellitus.
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54. CONT…
• Insulin management dependent on
• Pre-op glycemic control
• Insulin regimen
• Magnitude of surgery
• Timing and duration of surgery
• Resumption of patients usual diet.
• Minor surgery is defined as all day-only procedures, while major surgery
includes all procedures that require at least an overnight admission
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55. PATIENTS WHO REQUIRE INSULIN THERAPY
• This group includes patients with type 1 diabetes or patients with type 2 diabetes who
require day time insulin injections.
• Patients who take both evening and morning doses of insulin should take their usual
dose of evening short-acting insulin, but reduce their intermediate- or long acting
dose by 20% the night before surgery.
• On the morning of surgery, they should omit their short-acting insulin and reduce the
intermediate- or long-acting dose by 50% (and take this only if the fasting glucose is
>120 mg/dl)
• Premixed insulin → reduce their evening dose prior surgery by 20% and hold insulin
completely on the morning of procedure.
• Some patients receiving insulin may also take oral AHG.
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56. MAJOR SURGERY(MORNING LIST)
• Maintain the usual insulin doses and diet the day before, and fast from midnight.
• Omit usual morning insulin (AHG).
• Commence an insulin-glucose infusion prior to induction of anesthesia (or by
10:00hrs at the latest).
• Measure BGL at least hourly during the intra-operative period.
• Continue the insulin-glucose infusion for at least 24 hours postoperatively and
until the patient is capable of resuming an adequate oral intake
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56

57. MAJOR SURGERY(AFTERNOON LIST)
• Give a reduced dose of insulin before early breakfast in the morning. (reduced
bolus insulin plus 1/2 day time dose as intermediate/long acting insulin)
• Patients should arrive at the facility by 09:00hrs and BGLs should be monitored
closely in the pre-operative ward.
• Commence an insulin-glucose infusion before induction of anesthesia.
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58. PATIENTS ON ORAL AHG MEDICATION
(WITHOUT INSULIN)
• Stop AHG medication on the day of surgery.
• Restart AHG medication when patients are able to resume normal meals (except
possibly metformin and thiazolidinediones following cardiac surgery).
• Commence an I-G infusion if the BGL >10 mmol/L(180mg/dl); if surgery
is prolonged and complicated; or if the patient is usually treated with more than
one oral AHG agent.
• Subcutaneous insulin may be required post-operatively
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59. PATIENTS ON DIET ALONE
• For patients whose diabetes is maintained on diet alone and who are well
controlled (HbA1c < 6.5%), no specific therapy is required, but more frequent
BGL monitoring during the peri-operative period is recommended.
• During the procedure, BGLs should be checked hourly.
• BGL remains above 10 mmol/L (180mg/dl) in the pre- or peri-operative period,
an I-G infusion should be commenced and continued until they resume eating.
• If the patient does not become hyperglycemic following surgery, the patients
BGL should be monitored every 4 – 6 hours until they ‟ resume their usual
meals.
• Patients who are hyperglycemic peri- or post-operatively may require
supplemental insulin and/or the initiation of specific AHG
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60. INSULIN/DEXTROSE REGIMENS
The two widely used regimens are the
Insulin sliding scale and
The „Alberti‟ regimen.
INSULIN SLIDING SCALE
Insulin sliding scale uses 50 U of soluble Insulin diluted up to 50 ml with normal
saline and run at a rate according to the patient‟s blood glucose.
 Dextrose and potassium also need to be infused concurrently (e.g. 500 ml of 10%
dextrose plus 10 mmol potassium chloride at 100 ml/hour).
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61. SLIDING SCALE
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62. SLIDING SCALE
• The amount of Insulin
administered can be altered
easily without having to make up
a new mixture.
• Risk of a failure to administer
dextrose due to blockage,
disconnection or backflow.
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63. THE ALBERTI REGIMEN
• Combines Insulin, dextrose and potassium to remove the risk of accidental Insulin
infusion without dextrose.
• The amount of Insulin added to each bag depends on the patient‟s BGL, so new
mixtures of Insulin and dextrose have to be made up each time a change in Insulin
dose is required.
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64. 12/2/2019 DM 64

65. • ADVANTAGE
• Combines Insulin, dextrose and
potassium to remove the risk of
accidental Insulin infusion
without dextrose.
• DISADVANTAGE
• Costly and inefficient because it
may have to be done every hour
in some patients.
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66. FLUID MANAGEMENT
• Aims of fluid management:
• Provide glucose as substrate to prevent proteolysis, lipolysis and ketogenesis.
• Maintain blood glucose level between 6-10mmol/L where possible (acceptable range
4-12mmol/L).
• Optimize intravascular volume status.
• Maintain serum electrolytes within the normal ranges.
• Ringer’s lactate: lactate undergo gluconeogenesis in the liver and may complicate
blood sugar control when given in large volumes.
• Normal saline: infusions in large volume increase risk of hyperchloremic acidosis.
• Ringer’s Acetate: acetate metabolism is unchanged in patients with DM. rapid
infusion of high volume →vasodilation, myocardial depression.
• No ideal solution; either solution may be used judiciously.
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67. ANAESTHESIA AND DIABETES
12/2/2019 DM 67

68. CONCERNS…
DM affects oxygen transport by causing glucose binding to Hb.
Chronic kidney disease is asymptomatic in diabetic and usually advanced.
Autonomic dysfunction :
Exaggerated Hypotension
 Risk of hypothermia
Sympathetic response are blunted
 Silent MI
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69. CONT…
 Inhibits intestinal motility, delayed gastric emptying.
 Difficult Airway-
restricted joint movement(atlanto-occipital)
obesity
 Therapy related:
Sulphonylureas - hypoglycemia
 Metformin - lactic acidosis
 Incretins & amylin - delays gastric emptying, nausea
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70. DRUGS TO BE DISCONTINUED
:
• Metformin sensitize specific tissues to insulin, mediating efficient uptake of
glucose in muscle and fat while preventing hepatic glucose formation.
• Should be discontinued before surgery due to: Intraop hemodynamic instability
decrease renal perfusion risk of lactic acidosis.
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71. CONT…
• Mechanism of action is similar to that of metformin.
• Not associated with lactic acidosis.
• Discontinued as they are not insulin secretagogues.
• Increased cardiac events in patients on rosiglitazone.
• May also cause fluid retention in the postoperative phase
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72. CONT…
:
• trigger insulin production and may induce hypoglycemia in a fasting preoperative
patient.
• K+ channel blocking effects may interfere with myocardial ischemic
preconditioning increasing risk of cardiac complication.
• If a patient has mistakenly taken a sulfonylurea on the day of surgery, the
operation may still be completed; however, careful glucose monitoring is
imperative and IV dextrose may be required
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73. CONT…
:
• weaken the effect of oligosaccharidases and disaccharidases in the intestinal brush
border, effectively lowering the absorption of glucose after meals.
• In preoperative fasting states, this drug has no effect and thus should be
discontinued until the patient resumes eating.
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74. CONT…
: such as xenatide
• Hold on the day of surgery
• Decrease gastric motility.
• May delay restoration of proper gastrointestinal function during recovery.
:
• like sitagliptin and vildagliptin
• work by a glucose dependent mechanism (reducing the risk of hypoglycemia even
in fasting patients)
• May be continued if necessary
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75. PHARMACOLOGY
 Propofol – lipid loading lead to impaired metabolism in DM, decreased
lipid clearance.
Its of more concern when given in infusion.
Etomidate - decreases adrenal steroid genesis, decreased glycaemic
response to surgery.
Ketamine- may cause significant hyperglycemia
Midazolam –(high doses/infusion) ,decreases ACTH & Cortisol decreased
sympatho adrenal stimulation decreased glycemic response to surgery.
Alpha-2 adrenergic agonist – decreases sympathetic outflow from
hypothalamus, decreases ACTH improves glycemic control.
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76. 12/2/2019 DM 76

77. CONT…
Inhalationals
Halothane, enflurane and isoflurane, in vitro, inhibit the insulin response to
glucose in a reversible and dose‐dependent manner.
Muscle Relaxants:
 Succinyl choline should be avoided in patients with extensive peripheral
neuropathy due to risk of increased potassium release.
Atracurium and mivacurium are preferred in presence of renal dysfunction.
Rocuronium may be used in rapid sequence induction.
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78. GENERAL ANAESTHESIA
ADVANTAGES
• High dose opiate technique may be
useful to block the entire sympathetic
nervous system and the hypothalamic
pituitary axis.
• Better control of blood pressure in
patients with autonomic neuropathy.
DISADVANTAGES
• May have difficult airway. (“Stiff-joint
syndrome”)
• Full stomach due to gastroparesis.
• Controlled ventilation is needed as
patients with autonomic neuropathy
may have impaired ventilatory control.
• Aggravated haemodynamic response
to intubation.
• It may masks the symptoms of
hypoglycaemia
12/2/2019 DM 78

79. REGIONAL ANAESTHESIA
ADVANTAGES
• Regional anesthesia blunts the increases
in catecholamine ,cortisol, glucagon,
and glucose.
• Metabolic effects of anesthetic agents
avoided
• An awake patient – hypoglycemia
readily detectable.
• Decreased chance of Aspiration, PONV
and Thromboembolism.
• Rapid return to diet and Sc insulin/OHA
DISADVANTAGES
• If autonomic neuropathy is present,
profound hypotension may occur.
• Infections and vascular complications
may be increased (epidural abscesses are
more common in diabetics)
• Medicolegal concern of risk of nerve
injuries and higher risk of ischemic
injury due to use of adrenaline with LA
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80. THE POST-OPERATIVE PERIOD
• Insulin-glucose infusions should be continued until the patients can resume an
adequate diet.(or at least 24 hrs)
• I-G infusions should ideally be stopped after breakfast, and a dose of
subcutaneous insulin (or oral AHG) is given before breakfast.
• Hyperglycemia detected post-operatively in patients not previously known to
have diabetes should be managed as if diabetes was present, and the diagnosis
of diabetes reconsidered once the patient has recovered from their surgery.
• Diabetes medication requirements may be increased (or occasionally decreased)
in the post-operative period, and frequent BGL monitoring is therefore essential.
• Diabetes management expertise must be available for the post-operative
management of glycemic instability.
12/2/2019 DM 80

81. 12/2/2019 DM 81

82. 12/2/2019 DM 82