Diabetes; Surgical and Medical Illness

Question 1

If a diabetic patient becomes ill with other pathologies, what advice should the patient get in general? (5)

Answer 1

• increase frequency of blood glucose monitoring to 4 hourly or more frequently
• Encourage fluid intake aiming for at least 3 litres in 24hrs
• If unable to take struggling to eat may need sugary drinks to maintain carbohydrate intake
• It is useful to educate patients so that they have a box of ‘sick day supplies’ that they can access if they become unwell
• Access to a mobile phone has been shown to reduce progression of ketosis to diabetic ketoacidosis

Question 2

Peri-operative management of blood-glucose concentrations depends on which factors?

Answer 2

Duration of fasting

Timing of surgery ( morning or afternoon)

Usual treatment regimen (insulin, anti-diabetic drugs or diet)

Poor glycaemic control

Other co-morbidities, and the likelihood that the patient will be capable of self-managing their diabetes in the immediate post-operative period

Question 3

Patients who are having elective surgery, minor procedures in patients with good glycaemic control: what is the normal adjustment of their insulin both before and during the surgery?

Answer 3

Before:
On the day before the surgery, the patient’s usual insulin should be given as normal, other than once daily long-acting insulin analogues, which should be given at a dose reduced by 20 %.

During:
can be managed during the operative period by adjustment of their usual insulin regimen, which should be adjusted depending on the type of insulin usually prescribed

Question 4

For a patient having surgery, on the day before the surgery, the patient’s usual insulin should be given as normal, other than once daily long-acting insulin analogues. How should it be changed?

Answer 4

Once daily long-acting insulin analogues should be given at a dose reduced by 20 %

Question 5

When would a patient need to use VRIII (Variable Rate Intravenous Insulin infusion) during their surgery?

Answer 5

• Patient is undergoing a major procedure
• The surgery required a long fasting period of more than one missed meal
• Whose diabetes is poorly controlled

The VRIII continues until the patient is eating/drinking and stabilised on their previous glucose-lowering medication.

Question 6

On the day of surgery, what fluids should be given?

Answer 6

Start an intravenous substrate infusion of potassium chloride with glucose and sodium chloride (based on serum electrolytes which must be measured frequently), and infuse at a rate appropriate to the patient’s fluid requirements.

To prevent hypoglycaemia, this infusion must not be stopped while the insulin infusion is running

Question 7

At what blood-glucose level should an IV glucose 20% be started?

Answer 7

If blood-glucose drops below 6 mmol/litre, and blood-glucose checked every hour.

If blood-glucose drops below 4 mmol/litre

Question 8

If blood-glucose drops below 4 mmol/litre, what should the patient be given and how often should the blood-glucose be checked?

Answer 8

Give IV glucose 20%

Check blood-glucose every 15 minutes until its over 6 mmol/litre, where you can revert to checking blood-glucose every hour

Question 9

If blood glucose rises over 12 mmol/litre, what should be done for the patient?

Answer 9

Check ketones and consider other signs of diabetic ketoacidosis

Question 10

How should metformin be taken on
Day prior to admission for surgery,
Day of surgery (morning)
Day of surgery (afternoon)

Answer 10

Day prior:
Take as normal

Morning surgery:
If taken once or twice a day - take
as normal
If taken three times per day, omit lunchtime dose

Afternoon surgery:
If taken once or
twice a day – take as normal
If taken three times per day, omit lunchtime dose

Question 11

How should Sulfonylureas be taken on
Day prior to admission for surgery,
Day of surgery (morning)
Day of surgery (afternoon)

Answer 11

Day Prior:
Take as normal

Morning Surgery:
If taken once daily in the morning - omit the dose that day
If taken twice daily - omit the morning dose that day

Afternoon Surgery:
If taken once daily in the morning - omit the dose that day
If taken twice daily - omit both doses that day

Question 12

How should -gliptins (DPP IV inhibitors) be taken on:
Day prior to admission for surgery,
Day of surgery (morning)
Day of surgery (afternoon)

Answer 12

Day Prior:
Take as normal

Morning surgery:
Take as normal

Afternoon surgery:
Take as normal

Question 13

How should SGLT-2 inhibitors (-flozins) be taken on:
Day prior to admission for surgery,
Day of surgery (morning)
Day of surgery (afternoon)

Answer 13

Day Prior:
Take as normal

Morning surgery:
Omit on the day of surgery

Afternoon surgery:
Omit on the day of surgery

Question 14

How should Once Daily insulins (e.g. Lantus, Levemir) be taken on:
Day prior to admission for surgery,
Day of surgery (morning)
Day of surgery (afternoon)

Answer 14

Day Prior:
Reduce dose by 20%

Morning surgery:
Reduce dose by 20%

Afternoon surgery:
Reduce dose by 20%

Question 15

How should Twice daily Biphasic or ultra-long acting insulins (e.g. Novomix 30, Humulin M3) be taken on:
Day prior to admission for surgery,
Day of surgery (morning)
Day of surgery (afternoon)

Answer 15

Day Prior:
No dose change

Morning surgery:
Halve the usual morning dose. Leave evening dose unchanged

Afternoon surgery:
Halve the usual morning dose. Leave evening dose unchanged

Question 16

Which oral anti-diabetic medication should be stopped if a patient is becoming dehydrated?

Answer 16

Metformin should be stopped because of the potential impact upon renal function