Peri-Operative Care of Diabetic and Steroid Patients

Question 1

what is the body’s response to surgery?

Answer 1

it undergoes a stress response

Question 2

what is the main hormone activated in the surgical stress response?

Answer 2

cortisol

Question 3

what other hormones are activated in the surgical stress response?

Answer 3

catabolic hormones - glucagon, growth hormone, catecholamines

Question 4

true or false: insulin level increase during the surgical stress response?

Answer 4

false.

insulin levels drop

Question 5

what happens to plasma glucose levels in the surgical stress response?

Answer 5

they increase

Question 6

what effect does the surgical stress response have on the heart and blood supply?

Answer 6

• increases heart rate and cardiac output
• increased arterial blood pressure
• increased blood supply to brain and muscles

Question 7

what happens to the kidneys blood supply in the surgical stress response?

Answer 7

decreased blood flow to the kidneys

Question 8

why does the surgical stress response increase the risk of thrombus formation?

Answer 8

there is an increase if plasma free fatty acids, triglycerides, cholesterol, and glucose

Question 9

what negative effects does the surgical stress response have on CVS?

Answer 9

there is an increased risk of angina, MI, arrhythmias, AV/VF, and sudden death if the patient has risk factors

Question 10

what system controls the surgical stress response?

Answer 10

hypothalamic pituitary axis

Question 11

how often should diabetic patients have their glucose monitored intra-operatively?

Answer 11

BM measurements should be taken every 30 minutes

Question 12

how is the balance between insulin and plasma glucose maintained peri-operatively?

Answer 12

patients are put on a variable rate insulin infusion (VRII)

Question 13

what is the target glucose level in diabetic patients?

Answer 13

6mmol - 10mmol

Question 14

why is hypoglycaemia bad in the post-operative period?

Answer 14

it’s a lack of nutrients and will cause poor wound healing

Question 15

why is hyperglycaemia bad in the post-operative period?

Answer 15

it increased the risk of infection because bacteria love sugar - this will lead to poor wound healing

Question 16

true or false: all insulin is stopped before surgery

Answer 16

false.

basal insulin is maintained to prevent the patient from entering DKA

Question 17

why do patients on long-term steroids require special surgical management?

Answer 17

steroids are structurally similar to cortisol and act as negative feedback to shut down the HPA axis - therefore a stress response can’t take place

Question 18

why is the stress response so important in surgery?

Answer 18

it promotes wound healing and helps the body get better faster

Question 19

what is the importance of ACTH in the stress response?

Answer 19

when HPA axis is activated, it increases, increasing cortisol levels

Question 20

what are anaesthetists trying to avoid in patients on long-term steroids?

Answer 20

addisonian crisis

Question 21

what are the biological features of an addisonian crisis?

Answer 21

hypoglycaemia, hypotension, hyponatraemia, hyperkalaemia

Question 22

what are the clinical features of an addisonian crisis?

Answer 22

nausea, vomiting, confusion, tachycardia, coma

Question 23

what preventative measures can be taken in a surgical patient on long term steroids?

Answer 23

they are given IV hydrocortisone