1. Perioperative management of diabetes requires tight glucose control to prevent hyperglycemia and hypoglycemia. 2. Patients should be optimized before surgery with HbA1c <7% and preoperative blood glucose between 100-140 mg/dl. 3. During surgery, blood glucose should be monitored hourly and maintained between 100-200 mg/dl through insulin drips or oral medications depending on the patient's regimen. 4. Postoperative monitoring and management continues to prevent hyperglycemic or hypoglycemic complications.

1. PERI OPERATIVE MANAGEMENT
DR.N K AGRAWAL
DIABETES MELLITUS

6. MYTHS!
 DEXTROSE SHOULD NOT BE GIVEN !
 SHIFT THE PATIENT TO INSULIN !
 PRE OPERATIVE NO DEXTROSE- NO INSULIN !
 MANAGE PATIENT ON SLINDING SCALE !
 FOUR HOURLY BLOOD GLUCOSE !
 LOW SUGAR , HIGH PROTIEN DIET

7. FOLLOWING QUERIES WILL BE
ANSWERED.
WHY TO CONTROL DM?
PRE OPERATIVE PHASE-TO SHIFT TO INSULIN?
WHETHER TO STOP OR CONTINUE OHG ?
FASTING PHASE MANAGEMENT
CHALLENGES FOR ANESTHETIST
EFFECT OF ANESTHETIC AGENTS ?
GLUCOSE MONITORING
POST OPERATIVE MANAGEMENT

8. WHY TO CONTROL DM ?
 INTRA OPERATIVE PERIOD THE PATIENT MAY
HAVE -
HYPERGLYCEMIA
OR
HYPOGLYCEMIA

9. HYPERGLYCEMIA
 NON ENZYMATIC GLYCOSYLATION LEADS TO
DEPOSITION OF PROTIEN ON ENDOTHELIAL
CELL - WEAKENS IT- HENCE NON HEALING
 MACROGLUBULIN FORMED BY LIVER –
INCREASES BLOOD VISCOSITY- CELL OEDEMA
 HbA1c > 8.5%- DISTRUBS AUTOREGULATION

10. THE PATIENTS MAY LAND INTO
DKA
OR
HHGS

11.  PATIENT MAY HAVE-
CEREBRAL OEDEMA
DELAYED RECOVERY
DIABETIC COMA

12.  HIGHER BLOOD GLUCOSE LEVEL MAY
CAUSE
 DEALYED WOUND HEALING
 POST OPERATIVE INFECTION

13. HYPERGLYCEMIA AND INFECTION
POST OP GLUCOSE RISK RATIO INFECTION
 121-206 1%
 202-350 1.17%
 230-353 1.86%
 250-360 1.90%

14. HYPOGLYCEMIA
 BGL < 60 mg/dl
IT MAY LEAD TO DAMAGE OF VITAL ORGANS LIKE:
 BRAIN CELLS
 LIVER CELLS
 R.B. CELLS
 SUPRA RENAL GLAND
WHICH ARE SOLELY DEPENDANT ON GLUCOSE FOR
ENERGY
 50% DEXTROSE IS USED TO BRING BGL >100 mg/dl

15. PRE OPERATIVE PHASE
 WE NEED TO HAVE PROPER CONTROL OF
GLUCOSE LEVEL
RANGE: 100mg/dl - 140 mg/dl
 HbA1c < 7.5%
 SHORT FASTING PERIOD
 NO KETONES IN URINE

16. `
 CO MORBID CONDITIONS LIKE
 OBESITY
 IHD
 HT
 RENAL
 ANS
SHOULD BE EXPLAINED TO RELATIVES

17.  PATIENT AND RELATIVES SHOULD BE MADE
AWARE OF SIGNS OF HYPOGLYCEMIA IN THE
POST-OPERATIVE PERIOD

18.  ELECTIVE SURGERY MAY BE DELAYED
 IF KETONES ARE POSITIVE - TREAT IT FIRST

19. WHETHER TO SHIFT ALL
THE PATIENTS TO
INSULIN ?

20. RECENT RECOMMADATIONS
IF THE SURGERY IS PLANNED UNDER
 LOCAL ANESTHESIA
 NERVE BLOCK
 NEURO AXIAL BLOCK
 NO NEED TO SHIFT TO INSULIN
 NOTE: DM PATIENTS ARE SENSITIVE TO LOCAL
ANESTHETIC, HENCE LOWER DOSE IS NEEDED

22.  THIS PATIENTS MAY BE VERY WELL TAKEN FOR
SURGERY WITH ORAL HYPOGLYCEMIC DRUGS.
 NOTE: DM PATIENTS ARE SENSITIVE TO LOCAL
ANESTHETIC, HENCE LOWER DOSE IS NEEDED

23. DO ALL PATIENTS UNDER GA REQUIRED
TO SHIFT TO INSULIN ?
NO

24. CRITERIA
 PATIENTS IN WHOM ORAL FLUID CAN BE
STARTED WITHIN FOUR HOURS OF GENERAL
ANESTHESIA MAY BE CARRIED OUT WITH
ORAL HYPOGLYCEMIC DRUGS

25. SURGERIES LIKE-
CLOSE REDUCTIONS
LAP APPENDIX
LAP CHOLECYSTECTOMY
LAP TUBECTOMY etc. etc

26. WHICH PATIENTS ARE TO BE SHIFTED?
 PATIENTS IN WHICH POST OPERATIVE
PARALYTIC ILEUS IS EXPECTED
OR
PROLONGED VENTILATION
OR
ORAL FLUID IS PROHIBITED
ARE TO BE CONTROLLED ON INSULIN

27.  IF PATIENTS ARE ON ORAL HYPOGLYCEMIC IT
MAY REQUIRE
5 -7 DAYS TO SHIFT TO INSULIN
THIS IS BECAUSE OF HALF LIFE OF ORAL
HYPOGLYCEMIC DRUGS 36-60 HOURS

28. INTRA OPERATIVE PHASE
 THE STRESS OF SURGERY
 THE ANESTHETICS USED
MAY AFFECT BLOOD GLUCOSE LEVEL

29. THE STRESS OF SURGERY
 THIS RELEASES SOME CATABOLIC HORMONES,
 INHIBITS SOME ANABOLIC HORMONES LIKE
INSULIN
 LEADS TO HYPERGLYCEMIA

30.  ANESTHETIC AGENTS

31. BENZODIAZEPINES
REDUCES SECRETION OF ACTH
HENCE CORTISOL
DECREASES HYPERGLYCEMIC RESPONSE

32. OPIATES
 THEY PROVIDE - HAEMODYNAMIC
- HORMONAL
- METABOLIC STABILITY
 OPIATES BLOCKS ENTIRE SYMPATHETIC
ACTIVITY AND ALSO INHIBITS
HYPOTHALAMUS PITUTARY AXIS
 OPIATES REDUCES HYPERGLYCEMIC
RESPONES

33. INHALATIONAL AGENTS
 HALOTHANE, ENFLURANE AND ISOFLURANE
REDUCES INSULIN RESPONSE TO GLUCOSE
LEADS TO HYPERGLYCEMIA
HAS NEGATIVE INOTROPIC EFFECT

34. INDUCING AGENTS
 THEY ARE KNOWN TO REDUCE LIPID
CLEARANCE FROM CIRCULATION AND ALSO
DECREASE INSULIN RESPONSE
LEADS TO HYPERGLYCEMIA

35. MUSCLE RELAXANT
 SUCCINYL CHOLIN SHOULD BE USED
CAUTIOUSLY
 THIS PATIENT MAY HAVE HIGHER POTASSIUM

36. “SLIDING INSULIN SCALE”
HAS NO ROLE IN
PERI AND POST OPERATIVE MANAGMENT

37. CHALLENGES
 STIFF NECK SYNDROME
 OBESITY
 CORONARY ISCHEMIC DISEASE
 NEPHROPATHY
 RETINOPATHY
 AUTONOMIC SYSTEM IMBALANCE

38.  THE REASON OF THIS END ORGAN DAMAGE IS
THAT GLUCOSE COMPETES WITH OXYGEN TO
BE CARRIED TO TISSUE VIA HEMOGLOBIN
HENCE HYPOXIA OCCURS AT THIS LEVEL

39. FASTING PHASE
NON TIGHT CONTROL REGIME
 NBM FOR 4-6 HOURS
 BEFORE 2 HOURS OR DURING FASTING
HYPOGLYCEMIA CAN BE MANAGED WITH CLEAR
JUICE OR 5% DEXTROSE @ 2mg/kg/hr
 DO THE MORNING BLOOD SUGAR
 TRY TO KEEP BGL- 100 mg/dl - 140mg/dl

40. TIGHT CONTROL REGIME
 FASTING FOR 4-6 HOURS
 CLEAR WATER UPTO 2 HOURS
 NO SUGAR
 IF HYPOGLYCEMIA GLUCOSE 1mg/kg/hr
 KEEP BGL 80-120 mg/dl

41.  ALL PATIENTS UNDER INSULIN REGIME
REQUIRES BOTH DEXTROSE AND INSULIN
 DEXTROSE IS REQUIRED BY CELLS FOR ENERGY
 INSULIN REQUIRED FOR METABOLISM OF GLUCOSE AT
CELL MEMBRANE LEVEL

42.  PLEASE DO NOT AVOID INSULIN IF PATIENT IS
MANAGED ON INSULIN,
 INTRA OPERATIVELY
THIS MAY CAUSE KETOACIDOSIS

43. IV FLUID FOR PATIENTS ON ORAL
 BLOOD SUGAR
IF < 100 mg/dl - DNS
IF > 100mg/dl - NS OR RL

44. IF PATIENT ON INSULIN
 BLOOD SUGAR < 100 mg/dl - DNS
 BLOOD SUGAR >100 mg/dl - DNS with insulin
 MORNING DOSE- 20-40 % OF DAILY DOSE, SC SHORT
ACTING INSULIN IF NO INSULIN PUMP IS PLANNED
FOUR HOURS BEFORE
 PREPERATION OF INSULIN DRIP—
50 UNITS IN 250 ml ( NS WITH KCL)
 THAT IS 1 UNIT/ 5ML

45.  1 UNIT OF INSULIN METABOLISES
 2.5 gm GLUCOSE
 2.5 gm GIVES 10 KCAL
 MEANS 1 UNIT METABOLISE 10 KCAL
 TOTAL CIRCULATING BLOOD SUGAR IS AROUND 100mg/dl
 IF CIRCULATING BLOOD IS 5 Lit.
 100 X 50 =
5 GM OF GLUCOSE IN A NORMAL PATIENT IN
CIRCULATION

46.  1 UNIT OF INSULIN REDUCES BGL BY
 30-40 mg/dl

47.  SAME AS GLUCOSE
 1 GM OF PROTINE GIVES 4 KCAL

48. INTRA OPERATIVE MANAGMENT
DO BLOOD SUGAR EVERY HOUR
 INSULIN DOSE - BLOOD SUGAR/ 150
 ON STEROIDS - BLOOD SUGAR/100

49. WAY TO REMEMBER INSULIN DOSE
1 – 2--3
2– 3– 4
3– 4—5
1 UNIT FOR 200-300 mg/dl
2 UNIT FOR 300 -400 mg/dl
3 UNIT FOR 400-500 mg/dl
NO REFERENCE FOR IT

50. THIS IS NOT TRUE FOR PAEDIATRIC AGE
GROUP
THE DOSE SHOULD - 0.02 TO 0.05 U/kg

51.  PLEASE REMEMBER TO MONITOR
URINE KETONE

52. INTRA OP BLOOD SUGAR TO BE KEPT BETWEEN
100- 200 mg/dl
SUGAR TO BE MONITORED HOURLY
TREAT HYPO OR HYPERGLYCEMIA AS NEEDED

53.  PLEASE DO NOT DO BLOOD SUGAR WHEN A
SUGAR CONTAINIG FLUID IS RUNNING
 IT MAY SHOW HIGHER BGL BY 40-60 %

54. POST OPERATIVE
 START ORAL AS SOON AS POSSIBLE
 TWO HOURLY BLOOD SUGAR
 PATIENTS ON ORAL HYPOGLYCEMIC- FLUID TO BE
GIVEN AS EARLYAS POSSIBLE
 IF ON INSULIN TO BE MANAGED ON INSULIN PUMP
 NO OPIATES

55. REFERENCES
NHS- MANAGEMENT OF ADULT WITH
DIABETES UNDERGOING SURGERY AND
ELECTIVE PROCEDURE -2011
PERI OPERATIVE DIABETES MANAGEMENT
GUIDELINES- AUSTRALIAN DIABETES
SOCIETY -2012
MILLER”S ANESTHESIA TEXT BOOK

56. SUMMARY-1
PREOPERATIVE
OPTIMISATION - BGL-100-140 mg/dl
HbA1C < 7%
 FASTING FOR 4-6 HOURS ONLY
GIVE HYPOGLYCEMIA COVER WITH
 1-2 mg/kg/hr DEXTROSE
TAKE AS FIRST CASE

57. MAJOR SURGERY - NON INSULIN
NO ORAL HYPOGLYCEMIC IN MORNING
MONITOR SUGAR HOURLY
MAINTAIN BGL -100-180 mg/dl

58. ON INSULIN
30-40% OF DAILY REQUIRMENT SC OR
NO INSULIN IF INSULIN PUMP IS PLANNED
INTRA OPERATIVE
BGL 180-200 mg/dl TO BE MAINTAINED

59. POST OPERATIVE
 HOURLY BGL FOR FIRST 24 HOURS
 MANAGE ON INSULIN
OR
 GIVE ORAL HYPOGLYCEMIC WITH FIRST MEAL