Periop management of dm ajay

Dr. Ajay KanthariaDr. Ajay Kantharia

M.D.M.D. Hon. Physician & IntensivistHon. Physician & Intensivist::

Saifee HospitalSaifee Hospital

Sir H.N. HospitalSir H.N. Hospital

Smt. Dalvi HospitalSmt. Dalvi Hospital

In Charge of ICUIn Charge of ICU::

Dr. Bacha’s Nursing HomeDr. Bacha’s Nursing Home

Diabetes mellitus (DM) is a group of

metabolic diseases of impaired glucose homeostasis, due

to

absolute or relative lack of Insulin

Abnormality of glucose can be due to:

a defect in insulin secretion, increased insulin resistance, increased endogenous glucose

production by the liver or any combination of these factors.

The incidence of type I diabetes remains fairly fixed at 0.4% of the population.

The prevalence of type II DM is dramatically increasing. It is expected that the number of people with DM will increase from the 150 million today to 300 million by the year 2025 globally.

Diabetes is associated with – an increased requirement for surgical

procedures and – increased postoperative morbidity and

mortality. – Increased chance of complications

The stress of surgery itself results in metabolic disturbances that alter glucose homeostasis.

Glucose Homeostasis

Glucose Homeostasis

Glucose homeostasis is controlled primarily by the anabolic hormone insulin.

The catabolic hormones glucagon, catecholamine, cortisol, and growth hormone oppose the action of insulin. They are known as anti-insulin or counter-regulatory hormones.

Any stress (surgery, trauma, anesthesia, burns, or infection) is associated with increased metabolic demands and can affect glucose metabolism.

In the first phase of the stress response there is vasoconstriction, which limits blood loss after injury.

Fuels are mobilized from all available sources, but the provision of glucose for the brain has first priority.

High concentrations of epinephrine and glucagon stimulate glycogenolysis and gluconeogenesis.

This leads to moderate hyperglycemia.

Decreased peripheral uptake of glucose enhances the hyperglycemic effect.

Stress also induces insulin resistance in muscle, adipose tissue, and liver, probably at a post receptor level.

The insulin- dependent transport of glucose in adipose tissue and skeletal muscle decreases.

The type of anesthesia used during surgery may also influence the hyperglycemic response during surgery.

General anesthesia has been shown to result in higher blood glucose concentration, circulating catecholamines, cortisol, and glucagon compared to local and epidural analgesia.

Blood Glucose and Perioperative Outcome

Hypoglycemia OR Uncontrolled DM can lead to

– volume depletion from osmotic diuresis

– life-threatening conditions such as diabetic ketoacidosis and non-ketotic hyperosmolar coma

Other ProblemsOther Problems

Increased thrombogenesisIncreased thrombogenesis HypertensionHypertension InfectionInfection Overall cost increasesOverall cost increases

Perioperative Risk Assessment

All the underlying medical problems should be noted and addressed before surgery.

An important aspect of perioperative assessment is glycemic control.

Preoperative Preoperative AssessmentAssessment

““Fitness for surgery”Fitness for surgery”

What is the difference What is the difference in other surgical in other surgical

patients & a Diabetic patients & a Diabetic patient?patient?

Check Medical historyCheck Medical history– CVS, RS, GI, CNSCVS, RS, GI, CNS

H/o DM.. Duration, medication H/o DM.. Duration, medication past and present, dosage past and present, dosage

How is the glycemic controlHow is the glycemic control Any diabetic complications… Any diabetic complications…

retinopathy, nephropathy etcretinopathy, nephropathy etc

Check Renal functionCheck Renal function– Urine, Creatinine,Urine, Creatinine,

AnalgesicsAnalgesics Hypoglycemic episodes,… Hypoglycemic episodes,…

frequency, awareness….frequency, awareness….

Check the drugs and Check the drugs and namesnames

Check the dietary Check the dietary historyhistory

Hard Working OR Hardly Hard Working OR Hardly workingworking

Surgical detailsSurgical details

What is the surgery?What is the surgery? Which anesthesia?Which anesthesia? Time?Time? Duration?Duration? Post op ICU? Wards?Post op ICU? Wards?

Surgery can be defined as: Minor (those that do not require post op

fasting)

or

Major (any procedure requiring general anesthesia for more than two hours and requiring fasting)

Type I Diabetes

In type I diabetics, adequate glucose should be provided to prevent catabolism and starvation ketosis.

The physiologic amount of glucose required to prevent catabolism in the average nondiabetic adult is

5 gram/hr.

Plan should be to keep Blood Plan should be to keep Blood sugar between 150 to 180 mg%.sugar between 150 to 180 mg%.

Potassium replacement is Potassium replacement is requiredrequired

4 common scenario:4 common scenario: (1) Type 1 DM for Minor surgery(1) Type 1 DM for Minor surgery

– (a) With fasting(a) With fasting– (b) Without fasting(b) Without fasting

(2) Type 1 DM for major surgery(2) Type 1 DM for major surgery (3) Type II DM for Minor surgery (3) Type II DM for Minor surgery

– (a) With fasting(a) With fasting– (b) Without fasting(b) Without fasting

(4) Type II DM for Major surgery(4) Type II DM for Major surgery

Type 1 DM (Minor Type 1 DM (Minor Surgery)Surgery) Patients who require fasting for

minor surgery should not be administered their usual dose of insulin.

Glucose and electrolytes must be measured on the day of surgery. D5 NS (DNS) should be initiated. If the blood glucose is more than 200 mg/dl, rapid acting insulin should be given.

Type 1 DM (Minor Type 1 DM (Minor Surgery)Surgery)

Patients for minor surgery and do not require fasting should be administered one half of their daily dose of insulin and eat their regular food.

If the blood glucose is between 100-200 mg/dl, surgery can be done.

If the blood glucose is >200, 1/2NS and 10 mEq of potassium should be added to each 500 ml of the above solution, along with rapid acting insulin.

Type 1 DM (Major Type 1 DM (Major Surgery)Surgery) For major surgery, regular insulin

is administered intravenously in an infusion of 10% of dextrose in 1/2NS to which potassium chloride has been added (0.3 units of regular insulin per gram of glucose) and infused at 100ml/hr. (15units for one pint)

Intravenous InsulinIntravenous Insulin

Intermittent IV BolusIntermittent IV Bolus OROR Continuous IV InfusionContinuous IV Infusion

– Single solution Glu- Pot- Insulin DripSingle solution Glu- Pot- Insulin Drip– Separate Insulin drip Separate Insulin drip

Intravenous InsulinIntravenous InsulinIntermittent BolusIntermittent Bolus

In the intermittent bolus technique, 10 U of regular insulin is administered every 2 hours and supplemented by 5 U every 60 minutes for blood glucose levels greater than approximately 200 mg/dL.

Intravenous InsulinIntravenous InsulinContinuous InfusionContinuous Infusion 500 cc N.Saline + 50 units of 500 cc N.Saline + 50 units of

regular insulin.regular insulin.– Start at 1unit / hourStart at 1unit / hour– (10ml / hour)(10ml / hour)

50cc N. Saline + 50 units of 50cc N. Saline + 50 units of regular insulinregular insulin– 1 unit / hour ~ 1 ml / hour1 unit / hour ~ 1 ml / hour

It is important to remember that patients with type 1 diabetes have basal insulin requirements that must be met, even during fasting, to maintain metabolic control.

Type II DiabetesType II Diabetes(On Diet alone)(On Diet alone) NBM before surgeryNBM before surgery Hydration as per requirementHydration as per requirement Regular monitoring of Blood SugarRegular monitoring of Blood Sugar Small boluses of Short Acting Small boluses of Short Acting

InsulinInsulin May be able to stop insulin in few May be able to stop insulin in few

daysdays

Type II Diabetes

Patients undergoing minor surgical procedures and who are not fasting should be managed by using their normal diabetic regimen.

Preferably, surgery should be performed in the morning.

Patients who are taking oral hypoglycemic agents should continue their medication and eat their regular food.

Type II DM ( Major Type II DM ( Major Surgery)Surgery) Major surgery OR Minor surgery

(requiring fasting ) Patients should take regular

medication, except for those who take second generation sulfonylureas (glipizide, glimepiride, glyburide).

These agents should be stopped one day before surgical procedure because of their prolonged half-lives.

Type II DM ( Major Type II DM ( Major Surgery)Surgery)

Metformin, despite its short half-life should be stopped one day before, since it increases the risk of lactic acidosis due to perioperative dehydration, renal hypo-perfusion and tissue hypoxia.

Metformin should be restarted only after establishing normal renal function.

Type II DM ( Major Type II DM ( Major Surgery)Surgery) All other oral hypoglycemic

agents can be continued until the day of surgery, at which time patients are instructed not to take their normal morning dose.

Intraoperative Intraoperative Glucose requirementGlucose requirement Patients with diabetes should

receive approximately 5 g of glucose per hour (i.e., 5 % dextrose solution in water infused at 100 mL per hour) during surgery to prevent the development of hypoglycemia, ketosis, or protein breakdown.

Intraoperative Intraoperative Glucose requirementGlucose requirement 5% Dextrose @ 100 ml / hour5% Dextrose @ 100 ml / hour 10% Dextrose @ 50 m/ hour10% Dextrose @ 50 m/ hour

Postoperative Management

All diabetic patients who undergo major surgery should resume their normal dietary regimen and oral medication or insulin as soon as possible.

Intravenous infusion of D5 NS should be discontinued once this has been accomplished.


Type I diabetics who undergo minor surgical procedures should have their blood sugars checked every 4 hours. If the blood glucose levels is >250 mg/dl, subcutaneous (SC) rapid acting insulin should administered.


For patients undergoing outpatient surgery, For patients undergoing outpatient surgery, their preoperative regimen may be their preoperative regimen may be reinstituted when the patient resumes eating. reinstituted when the patient resumes eating.

An exception to this approach exists when the An exception to this approach exists when the procedure is performed in conjunction with procedure is performed in conjunction with iodinated radiocontrast dye and the patient is iodinated radiocontrast dye and the patient is treated with a biguanide. treated with a biguanide.

The biguanide should not be resumed for 72 The biguanide should not be resumed for 72 hours postoperatively, when serum creatinine hours postoperatively, when serum creatinine is measured to document the absence of dye-is measured to document the absence of dye-induced renal toxic effects and normal renal induced renal toxic effects and normal renal function.function.


If unstable DM control….If unstable DM control….– start insulin infusionstart insulin infusion

Post op Surgeon’s Post op Surgeon’s orderorder 1 .. 5% dextrose1 .. 5% dextrose 1.. Ringer lactate1.. Ringer lactate 1.. DNS1.. DNS 1.. N S1.. N S 1.. 5% dextrose1.. 5% dextrose

Few common problemsFew common problems

In a diabetic patient:In a diabetic patient:– Autonomic neuropathy / Autonomic neuropathy /

gastroparesisgastroparesis– Vomiting / constipationVomiting / constipation– Urine retentionUrine retention

Thank YouThank You

Periop management of dm ajay

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