Diabetes Mellitus Flashcards
Insulin changes before surgery for minor procedures (1 meal missed) if good diabetes control
Give 80% of normal long acting insulin on day before surgery
Adjust normal insulin during surgery
Insulin changes before surgery for major procedures (>1 meals missed) or if poor diabetes control
Give long acting insulin at 80% usual dose from the day before
Stop short-acting insulin on the day of surgery and start variable rate insulin infusion
Start IV potassium chloride + glucose + NaCl on day of surgery, and continue as long as VRII is running
Give IV glucose if blood glucose drops below 6 at any point
Restarting SC insulin from VRII after surgery
Switch back to SC with the first meal post-surgery (not lunch if originally biphasic insulin), as long as patient can tolerate eating and drinking without vomiting
Give SC insulin before meal, then stop VRII 30-60mins after meal
Patients with diabetes requiring emergency surgery Mx
If suspicion of DKA: Delay surgery and treat
Otherwise, all patients with T1DM/T2DM require variable rate insulin infusion + IV fluids
Mx of antidiabetic drugs during surgery
If VRII:
- Stop all antidiabetic drugs apart from GLP-1 agonists and metformin
Pioglitazone/sulfonylureas: Omit on morning of surgery
Metformin (if risk of AKI or missing >1 meal): Omit, start VRII if metformin normally more than OD
Metformin (if only missing 1 meal and renal function ok): Continue as normal, omit lunchtime dose if TDS
Complications of Diabetes
Microvascular disease
- Neuropathy
- Peripheral neuropathy (Leading to Charcot
arthropathy, neuropathic pain)
- Autonomic neuropathy (leading to
gastroparesis, postural hypotension,
neuropathic bladder)
- Nephropathy
- 1st sign is microalbuminuria
- Leads to CKD - Retinopathy
- Leads to sight loss via retinal detachment and vitreous haemorrhage
Macrovascular disease
- Ischaemic heart disease
Other
Psychosocial
Metabolic (DKA, HHS, Hypoglycaemia)
Diabetic neuropathic pain Mx
- Give neuropathic pain agent (amitriptyline)
- Switch to different neuropathic pain agent
Tramadol can be used short term for exacerbations
How does a diabetic foot develop
Peripheral neuropathy: Repetitive minor trauma leading to deformity
Peripheral arterial disease: Leading to critical limb ischaemia and gangrene
Increased susceptibility to infection as ulcer develops which predisposes to gangrene
Diabetic foot Mx
Treatment of acutely diseased foot
Rest
Analgesia
Off-loading of pressure with total contact cast
Control of infection: Soft tissue sample (if infection present) and start abx
Control of ischaemia
Wound debridement: Sharp debridement of necrotic tissue (essential, and better for crusted lesions)
Prevention of further lesions
Daily examination
Appropriate footwear
Risk factors for diabetic foot ulceration
Poor glycaemic control
Male
Previous ulceration
Diabetic foot Ix
Examination of ulcer w/ gentle sterile probe (SINBAD) § Site § Ischaemia § Neuropathy § Bacterial infection § Area § Depth
Probe-to-bone test: Assess for possibility of osteomyelitis (if you can reach the bone, likelihood of osteomyelitis is increased, so should do radiographs)
Acute Charcot arthropathy presentation and Ix
Redness, warmth, joint swelling and deformity with intact skin in the presence of peripheral neuropathy
Ix: Weight bearing XR
Acute Charcot Arthropathy Mx
Off-loading device
Diabetic foot prevention service
Diabetic nephropathy monitoring
Yearly A:CR and eGFR measurement for microalbuminuria If positive (>3), do early morning urine sample
Diabetic nephropathy Mx
Conservative Weight loss Diet Exercise Smoking cessation Tight glycaemic control
ACEi/ARB
Dialysis and kidney transplant
