Perioperative Perioperative Management of Management of

DiabetesDiabetes

Dr Shahjada SelimMBBS MD (EM)

Registrar (Medicine)ShSMCH

Importance of control l ing Importance of control l ing Diabetes in SurgeryDiabetes in Surgery

It is critical to control diabetes before, during and after surgery (pre, per and postoperatively) to improve outcome ofsurgery or to prevent complications.

Hyperglycemia during surgery may produce:1. Dehydration (Osmotic Diuresis)2. Electrolyte imbalance3. Impair wound healing4. Increase infection rate5. Chance to develop keto acidosis6. Has detrimental effect on CVS and renal function.

About 25% diabetic patient need surgery.

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Hyperglycemia leads to impaired wound Hyperglycemia leads to impaired wound healing and deficient formation of healing and deficient formation of granulation t issue.granulation t issue.

The chemotactic, phagocytic, and The chemotactic, phagocytic, and bactericidal activity of the neutrophils are bactericidal activity of the neutrophils are deficient.deficient.

there is impaired humoral host defense there is impaired humoral host defense mechanism and abnormal complement mechanism and abnormal complement function.function.

As..As..

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Metabolic sequelae in surgical patientMetabolic sequelae in surgical patient

Increased glycogenolysis, Increased glycogenolysis, gluconeogenesis andgluconeogenesis and

hyperglycemia.hyperglycemia.

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……………….Metabolic sequelae in surgical patient.Metabolic sequelae in surgical patient

Decreased glucose uti l ization due to-Decreased glucose uti l ization due to- Lipolysis with increased FFA Lipolysis with increased FFA

productionproduction Protein breakdownProtein breakdown nitrogen lossnitrogen loss urea productionurea production sodium retension & potassium sodium retension & potassium

execretion and alteration of water execretion and alteration of water metabolism ( increased ADH and metabolism ( increased ADH and increased aldosterone secretion ) increased aldosterone secretion )

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Determinants of Management Determinants of Management Plan in DiabetesPlan in Diabetes

Type of DMType of DM DietDiet Drugs: Insulin or OHADrugs: Insulin or OHA Metabolic statusMetabolic status Vascular status: cardiac, renal, Vascular status: cardiac, renal,

cerebralcerebral

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……………… Determinants of the management planDeterminants of the management plan

Surgery: Surgery: Type: emergency or electiveType: emergency or elective Minor or major procedureMinor or major procedure Type of anesthesiaType of anesthesia Post operative oral intake Post operative oral intake

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Pre-operative managementPre-operative management

Metabolic stress of surgery and Metabolic stress of surgery and anesthesia cause increased anesthesia cause increased production of catecholamine, production of catecholamine, glucocorticoids, glucagon, and growth glucocorticoids, glucagon, and growth hormone al l of which result in hormone al l of which result in hyperglycemia in the pre-operative hyperglycemia in the pre-operative period.period.

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Pre-operative managementPre-operative management The glycemic control is aimed to The glycemic control is aimed to

achieve a fasting plasma glucose of < achieve a fasting plasma glucose of < 7.5 mmol/l and post prandial plasma 7.5 mmol/l and post prandial plasma glucose of < 10 mmol/l.glucose of < 10 mmol/l.

Insulin dependent diabetic patients can Insulin dependent diabetic patients can be admitted 2-3 days prior to surgery to be admitted 2-3 days prior to surgery to achieve satisfactory control.achieve satisfactory control.

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Cont.Cont.

In T2DM patients, i f the control is good In T2DM patients, i f the control is good with OHAs, these drugs are continued with OHAs, these drugs are continued and stopped on the day of the surgery.and stopped on the day of the surgery.

If glycemic control is not good with If glycemic control is not good with OHAs, the drugs are stopped one week OHAs, the drugs are stopped one week before surgery and admitted for insulin before surgery and admitted for insulin therapy.therapy.

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Cont.Cont.

If glycemic control is not good with If glycemic control is not good with insulin, the doses should be intensif ied insulin, the doses should be intensif ied with multiple dose regimen (split mixed with multiple dose regimen (split mixed of basal bolus).of basal bolus).

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Subcutaneous insulin therapy after Subcutaneous insulin therapy after admissionadmission

In elective surgery cases, start short acting (3 t ime daily) and intermediate acting (2 t imes daily) insulins are started.

When the fasting plasma glucose is >7.5 mmol/l, increment by 2-4 units of intermediate acting insulin at night is needed.

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…… .Subcutaneous insulin therapy after admission.Subcutaneous insulin therapy after admission

When the prediner plasma glucose is When the prediner plasma glucose is >7.5 mmol/l, give 2-4 units of soluble >7.5 mmol/l, give 2-4 units of soluble insulin subcutaneously before breakfast insulin subcutaneously before breakfast next day and then monitor before next day and then monitor before prediner blood sugar.prediner blood sugar.

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……..Subcutaneous insulin therapy after admission..Subcutaneous insulin therapy after admission

When 2ABF plasma glucose is >10 When 2ABF plasma glucose is >10 mmol/l, increment by 2-4 units of short mmol/l, increment by 2-4 units of short acting insulin in the morning is needed.acting insulin in the morning is needed.

When 2AL plasma glucose is >10 When 2AL plasma glucose is >10 mmol/l, increment by 2-4 units of short mmol/l, increment by 2-4 units of short acting insulin before lunch is needed.acting insulin before lunch is needed.

When 2AD plasma glucose is >10 mmol/l, When 2AD plasma glucose is >10 mmol/l, increment by 2-4 units of short acting increment by 2-4 units of short acting insulin before diner is needed.insulin before diner is needed.

All doses are for the next day.

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………… Subcutaneous insulin therapy after admissionSubcutaneous insulin therapy after admission

For every 2.2mmol/l rise in premeal sugar , pre-meal one unit of soluble insulin is added to the previous dose of pre-meal insulin

If the blood sugar level is more than 16.6 mmol/l, 15 units of soluble insulin pre-meal three times a day is tried.

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On the day of surgeryOn the day of surgery

It is preferable to take diabetic patients for surgery in the morning as first case.

Normally the requirement of insulin is 0.3 U to metabolize 1gm of glucose.

When FPG < 6 mmol/l, no insulin is given except 5% glucose.

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On the day of surgeryOn the day of surgery

When FPG 6 -9 mmol/l, glucose with 5 units soluble insulin should be infused.

For FPG 9-11mmol/l, 5 % glucose with 8 U of soluble insulin is infused.

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Cont.Cont.

If FPG is 11-14 mmol/l, 5 % glucose with 10 U of soluble insulin should be continued.

Values between 14-16.6 mmol/l needs normal sal ine with 6-8 U .

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Cont.Cont. If the blood sugar > 16.6 mmol/l, 8-10 If the blood sugar > 16.6 mmol/l, 8-10

U are added to normal saline and U are added to normal saline and surgery is delayed for few hours t i l l surgery is delayed for few hours t i l l satisfactory glycemic control is satisfactory glycemic control is achieved.achieved.

All the above infusions are given at the All the above infusions are given at the rate of 100-120 ml / h .rate of 100-120 ml / h .

GKI protocol  (Glucose-Potassium-Insulin):

Very important regimen: 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 > 10mmol/l.

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Emergency surgeryEmergency surgery

The Endocrinology team/consultant on call The Endocrinology team/consultant on call should be contacted about all patients with should be contacted about all patients with diabetes who require emergency surgerydiabetes who require emergency surgery

In preparation for emergency surgery, the pt In preparation for emergency surgery, the pt should first be assessed clinically and should first be assessed clinically and biochemically (blood gas including glucose biochemically (blood gas including glucose and bedside ketones test, along with U&E, and bedside ketones test, along with U&E, FBE and other pre-op bloods as required).FBE and other pre-op bloods as required).

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Minor surgeryMinor surgery

For minor surgery the antidiabetic drugs and insulin are stopped on the day of surgery. Once the surgery is over, the patient is permitted to resume oral feeds the antidiabetic drugs are started with half the dose which the patient was originally taking, on the second post operative day full dose of the oral drugs and or insulins should be started.

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Practical aspectsPractical aspects

1.1. Whatever is the pattern of infusion, the blood Whatever is the pattern of infusion, the blood sugar has to be checked every tow hours and sugar has to be checked every tow hours and the f low rate is adjusted.the f low rate is adjusted.

2.2. Intra and post operative potassium monitoring Intra and post operative potassium monitoring should be done and corrected appropriately.should be done and corrected appropriately.

3.3. A few hours after surgery there wil l be A few hours after surgery there wil l be reduction in the insulin requirement as the reduction in the insulin requirement as the elevated counter hormones due to surgical elevated counter hormones due to surgical stress wil l decline.stress wil l decline.

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Special situationsSpecial situations

1.1. Blood sugar may rapidly fall after Blood sugar may rapidly fall after surgical drainage of an infected area.surgical drainage of an infected area.

2.2. Type 2 diabetes can be safely switched Type 2 diabetes can be safely switched over to oral drugs after a week or so.over to oral drugs after a week or so.

3.3. In coronary artery bypass surgery and In coronary artery bypass surgery and during and after renal transplantation, during and after renal transplantation, the insulin requirements wil l be the insulin requirements wil l be exceptionally high and should be exceptionally high and should be continued for at least 6 months.continued for at least 6 months.

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Post operative managementPost operative management

With the resumption of oral feeds With the resumption of oral feeds subcutaneous insulin can be started.subcutaneous insulin can be started.

T2DM patients can resume their oral T2DM patients can resume their oral antidiabetic drugs after week if there is antidiabetic drugs after week if there is no complications of surgery.no complications of surgery.

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Intravenous f luidsIntravenous f luids

Dextrose saline / normal saline is used Dextrose saline / normal saline is used if blood pressure is low or normal.i f blood pressure is low or normal.

If there is hypertension half normal If there is hypertension half normal saline or 5 % dextrose is given.saline or 5 % dextrose is given.

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Intravenous f luidsIntravenous f luids

For normal metabolism 50 gm glucose is For normal metabolism 50 gm glucose is required every 8 hours for energy and to required every 8 hours for energy and to avoid ketosis, to meet this demand at avoid ketosis, to meet this demand at least 1000 cc 5 % glucose every 8 h wil l least 1000 cc 5 % glucose every 8 h wil l be required.be required.

In situations requiring f luid restriction In situations requiring f luid restriction 10% dextrose can be infused instead of 5 10% dextrose can be infused instead of 5 % with double the dose of insulin.% with double the dose of insulin.

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TargetsTargets

To make patients safe for surgery, we need To make patients safe for surgery, we need an understanding and team work between an understanding and team work between the surgeon, anesthetist and diabetologist.the surgeon, anesthetist and diabetologist.

When the patient is under anesthesia the When the patient is under anesthesia the ideal is to have diabetic therapy supervised ideal is to have diabetic therapy supervised by a diabetic team where available.by a diabetic team where available.

Case 1Case 1 60 year old, 60 kg man, height 165 60 year old, 60 kg man, height 165

cm; scheduled for abdominoperineal cm; scheduled for abdominoperineal resection of Ca. rectumresection of Ca. rectum

Known diabetic on Metformin and Known diabetic on Metformin and Glibenclamide, BD doseGlibenclamide, BD dose

Hypertension, CAD under checkHypertension, CAD under check BG: (F) = 7, (PP) = 9 mmol/l.BG: (F) = 7, (PP) = 9 mmol/l.

Switch over to insulin pre-op? Switch over to insulin pre-op? Pre-op orders?Pre-op orders?

Case 1 60 year old, 60 kg man, height 165 60 year old, 60 kg man, height 165

cm; scheduled for abdominoperineal cm; scheduled for abdominoperineal resection of Ca. rectumresection of Ca. rectum

Known diabetic on Metformin and Known diabetic on Metformin and Glibenclimide, BD doseGlibenclimide, BD dose

Hypertension, CAD under checkHypertension, CAD under check BG: (F) = 120, (PP) = 170 mg.dlBG: (F) = 120, (PP) = 170 mg.dl - 1- 1

Morning BG=5; ½ h intra-op=8.5 Morning BG=5; ½ h intra-op=8.5 mmol/l.mmol/l.

Intra-op fluids and insulin?Intra-op fluids and insulin?

Case 2Case 2 40 year old, 45 kg lady Known diabetic on oral antihyperglycemics High grade fever x 1wk, vomiting x t i l l 2

days back, altered sensorium x 12 h P=120 bpm, BP=70/40, BG=470 mg.dl - 1, Blood Ketones (+++), pH=6.8, Na +-116, K +-

3.4, HCO 3-10, P CO2- 34, P O 2- 78 mmHg Emergency laparotomy Yes/No? How quickly? What t i l l

then?

Yes!Yes! 2-3 h may be enough 2-3 h may be enough

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Surgery with DKA Surgery with DKA

If ketoacidosis is present, treatment according to If ketoacidosis is present, treatment according to the the diabetic ketoacidosis protocoldiabetic ketoacidosis protocol should be  should be commenced immediately and the patient's commenced immediately and the patient's circulating volume and electrolytes stabilised circulating volume and electrolytes stabilised before surgery.  before surgery.  

Where DKA is present, initial insulin infusion Where DKA is present, initial insulin infusion rates will be 0.1U/kg/hr (or 0.04U/kg/hr). rates will be 0.1U/kg/hr (or 0.04U/kg/hr). 

This rate should be continued until ketones have This rate should be continued until ketones have cleared and acidosis has corrected (see DKA cleared and acidosis has corrected (see DKA protocol)protocol)

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……. Surgery with DKA . Surgery with DKA

Once ketones have cleared and acidosis has Once ketones have cleared and acidosis has corrected, the insulin infusion rates may be corrected, the insulin infusion rates may be reduced and the dextrose concentration of i.v. reduced and the dextrose concentration of i.v. fluids adjusted as appropriate to maintain BGLs fluids adjusted as appropriate to maintain BGLs between 6-10 mmol/l. Maintenance insulin between 6-10 mmol/l. Maintenance insulin infusion rates once ketosis/acidosis has fully infusion rates once ketosis/acidosis has fully cleared are usually in the range of 0.02-cleared are usually in the range of 0.02-0.03U/kg/hr; the endocrinology team will advise 0.03U/kg/hr; the endocrinology team will advise on this.  on this.  

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……. Surgery with DKA . Surgery with DKA

The insulin infusion is made up by adding 50 The insulin infusion is made up by adding 50 units (0.5 ml) of regular insulin (Actrapid 100 U) units (0.5 ml) of regular insulin (Actrapid 100 U) to 49.5 ml 0.9% NaCl (1 unit/ml solution). Short to 49.5 ml 0.9% NaCl (1 unit/ml solution). Short acting insulins can also be used.acting insulins can also be used.

The insulin infusion may run as a sideline with The insulin infusion may run as a sideline with the maintenance fluids via a three-way tap, the maintenance fluids via a three-way tap, provided a syringe pump is used. Ensure that the provided a syringe pump is used. Ensure that the insulin is clearly labeled.insulin is clearly labeled.

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……. Surgery with DKA . Surgery with DKA

The initial rate of the insulin infusion should The initial rate of the insulin infusion should be be 0.02 - 0.03U/kg/hr0.02 - 0.03U/kg/hr  (note that this  (note that this maintenance rate is much lower than the maintenance rate is much lower than the rate required to treat DKA).  Start with rate required to treat DKA).  Start with 0.02U/kg/hr if BGL is <10.0 mmol/l; 0.02U/kg/hr if BGL is <10.0 mmol/l; 0.03U/kg/hr if BGL >10.0 mmol/l.0.03U/kg/hr if BGL >10.0 mmol/l.

Confounding factors in a Confounding factors in a diabetics for emergency surgerydiabetics for emergency surgery

Usually associated with infective process pronounced hyperglycemia,

dehydration and hypovolumia metabolic decompensation ± DKA/ HHS

Thank You AllThank You All