PERI OPERATIVE MANAGEMENT DR.N K AGRAWAL DIABETES MELLITUS
Jul 15, 2015
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
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
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
HYPERGLYCEMIA AND INFECTION
POST OP GLUCOSE RISK RATIO INFECTION
121-206 1%
202-350 1.17%
230-353 1.86%
250-360 1.90%
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
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
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
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
CRITERIA
PATIENTS IN WHOM ORAL FLUID CAN BE STARTED WITHIN FOUR HOURS OF GENERAL ANESTHESIA MAY BE CARRIED OUT WITH
ORAL HYPOGLYCEMIC DRUGS
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
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
THE STRESS OF SURGERY
THIS RELEASES SOME CATABOLIC HORMONES,
INHIBITS SOME ANABOLIC HORMONES LIKE INSULIN
LEADS TO HYPERGLYCEMIA
OPIATES
THEY PROVIDE - HAEMODYNAMIC
- HORMONAL
- METABOLIC STABILITY
OPIATES BLOCKS ENTIRE SYMPATHETIC ACTIVITY AND ALSO INHIBITS HYPOTHALAMUS PITUTARY AXIS
OPIATES REDUCES HYPERGLYCEMIC RESPONES
INHALATIONAL AGENTS
HALOTHANE, ENFLURANE AND ISOFLURANE
REDUCES INSULIN RESPONSE TO GLUCOSE
LEADS TO HYPERGLYCEMIA
HAS NEGATIVE INOTROPIC EFFECT
INDUCING AGENTS
THEY ARE KNOWN TO REDUCE LIPID
CLEARANCE FROM CIRCULATION AND ALSO
DECREASE INSULIN RESPONSE
LEADS TO HYPERGLYCEMIA
CHALLENGES
STIFF NECK SYNDROME
OBESITY
CORONARY ISCHEMIC DISEASE
NEPHROPATHY
RETINOPATHY
AUTONOMIC SYSTEM IMBALANCE
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
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
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
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
PLEASE DO NOT AVOID INSULIN IF PATIENT IS MANAGED ON INSULIN,
INTRA OPERATIVELY
THIS MAY CAUSE KETOACIDOSIS
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
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
INTRA OPERATIVE MANAGMENT
DO BLOOD SUGAR EVERY HOUR
INSULIN DOSE - BLOOD SUGAR/ 150
ON STEROIDS - BLOOD SUGAR/100
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
INTRA OP BLOOD SUGAR TO BE KEPT BETWEEN
100- 200 mg/dl
SUGAR TO BE MONITORED HOURLY
TREAT HYPO OR HYPERGLYCEMIA AS NEEDED
PLEASE DO NOT DO BLOOD SUGAR WHEN A SUGAR CONTAINIG FLUID IS RUNNING
IT MAY SHOW HIGHER BGL BY 40-60 %
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
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
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
MAJOR SURGERY - NON INSULIN
NO ORAL HYPOGLYCEMIC IN MORNING
MONITOR SUGAR HOURLY
MAINTAIN BGL -100-180 mg/dl
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
POST OPERATIVE
HOURLY BGL FOR FIRST 24 HOURS
MANAGE ON INSULIN
OR
GIVE ORAL HYPOGLYCEMIC WITH FIRST MEAL