Diabetes Mellitus

Question 1

A 35-year-old female patient has been listed for an urgent laparoscopic cholecystectomy for ascending cholangitis. She has a history of type I diabetes mellitus but no other medical problems. She has a heart rate of 128, a blood pressure of 83/67 and has been vomiting.

What are your key concerns when assessing this patient on the ward?

Answer 1

• Observations indicate that she may be severely dehydrated and/or septic so will need urgent assessment and resuscitation prior to an anaesthetic.
• Diabetic ketoacidosis may also be present which requires investigation
  and rapid intervention.
• The history of vomiting increases the aspiration risk at induction
  (necessitating a rapid sequence induction).
• The patient is a type I diabetic and will need a thorough medical
  history including the duration, treatment and blood glucose control
  as well as any associated micro or macro-vascular complications.
• Given the history of cholangitis and vomiting, she may require an
  intravenous insulin and dextrose infusion perioperatively.

Question 2

Why is this patient at higher risk of complications during the perioperative period?

Answer 2

• Perioperative sepsis is an indicator for increased morbidity, mortality and postoperative complications.
• Any micro or macro-vascular complications of diabetes, particularly cardiac or renal comorbidities, increase the risk of both medical and surgical complications during the perioperative period.
• This patient is at high risk of hyper or hypoglycaemia due to the lack of oral intake, infection and iatrogenic causes, such as incorrect or unsuitable insulin prescribing or administration.
• Patients with pre-existing poor glucose control or inappropriate perioperative glucose control are at higher risk of surgical-site infections and poor wound healing.
• Patients with diabetes are more prone to electrolyte imbalance, particularly if being treated for diabetic ketoacidosis.

Question 3

When you see the patient on the ward, her blood glucose level is 32 mmol/L.

How do you proceed?

Answer 3

Initial approach:
* Rapid ABCDE assessment and escalation to senior surgical and medical teams and intensive care if appropriate.

• Ensure large-bore intravenous access.
• Early investigations should include an arterial blood gas (with lactate), blood ketone level, full set of baseline bloods, septic screen
  and bedside observations.
• Multidisciplinary discussion regarding urgency of surgery and
  treatment of likely diabetic ketoacidosis.

Question 4

When you see the patient on the ward, her blood glucose level is 32 mmol/L.

How do you proceed….continued?

Answer 4

Initial treatment:
* Apply 100% oxygen via a non-rebreathe mask.

• Recognition and treatment of suspected sepsis should focus on the “sepsis six”:
• Intravenous antibiotics.
• Fluid resuscitation.
• Urinary catheter.
• Blood cultures.
• Lactate.
• Oxygen.
• Follow the local guidelines for management of diabetic ketoacidosis, to include:
• Fixed rate insulin infusion (0.1 U/kg/hour).
• Resuscitative fluids – regimen of 0.9% sodium chloride (± potassium chloride). The patient may need several litres of fluid
  and should be continually reassessed.
• 10% dextrose (or similar) should be considered when the capillary blood glucose level has decreased to a suitable level.
• Capillary blood glucose and ketones should be monitored frequently.
• Strict fluid balance charting.
• Treatment of the underlying cause is essential but should be discussed
  with seniors owing to the complex nature of this case. Postoperative high dependency or intensive care and early assessment by the inpatient diabetic team should be considered.

Question 5

The patient undergoes a laparoscopic cholecystectomy the following day.

What is your plan for postoperative analgesia?

Answer 5

• Intravenous fentanyl boluses in recovery titrated to effect.
• Regular postoperative co-codamol with tramadol as rescue analgesia.
• Judicious use of NSAIDs due to risk of acute kidney injury.
• Buccal prochlorperazine.
• Opioid sparing agents if possible to minimise gastrointestinal side
  effects and return the patient to oral intake and their regular insulin therapy soon as possible.