Perioperative Diabetes

Question 1

What is the surgical stress response?

Answer 1

-Increased: catecholamines, GH, glucagon, cortisol and ACTH
-Decreased: insulin levels and insulin resistance
Result = glycogenolysis and gluconeogenesis with raised BSLs, protein catabolism, lipolysis, FFA production, ketone bodies.

Question 2

Why is it important to have good glycemic control preoperatively?

Answer 2

Hyperglycemia:
- increases wound infection
-impairs wound healing
-worsens outcome after neurologic damage and MI
-induces osmotic diuresis that may lead to dehydration / electrolyte disturbance
TIDM may –> DKA

Question 3

Preop assessment of DM for perioperative DM Mx?

Answer 3

• Determine type of DM
• Assess current mx
• Check adequacy of control
• Diagnose complications
• Evaluate other RFx for CVD
• Formulate a plan for perioperative mx of glucose

Question 4

What are the complications of diabetes relative to the perioperative period?

Answer 4

• Metaboic disturbance
• Atherosclerosis
• Cardiomyopathy
• Microangiopathy
• Neuropathy
• Stiff joints and glycosylation of tissues (may indicate difficulty w/ intubation)
• Reduction in wound healing and infection

Question 5

Why is it important to identify ?atherosclerosis of DM pre op workup?

Answer 5

• Increased risk of MI (often silent)

- Revascularise if indicated on medical grounds

Question 6

Why is it important to identify ?autonomic neuropathy of DM pre op workup?

Answer 6

Increased risk of haemodynamic instability and gastroparesis ==> regurgitation and aspiration, silent MI

Question 7

Why is it important to identify ?peripheral neuropathy of DM pre op workup?

Answer 7

• Pre existing neurologic sx (document if considering regional anaesthesia)
• Intra operative nerve injury
• may have chronic pain and be on opioids etc

Question 8

What are the cornerstones of DM perioperative Mx?

Answer 8

• Define whether pre op control adequate
• Monitor BSL regularly peri-operatively
• Administer insulin and glucose until pt can tolerate diet and have normal Rx

Question 9

TIIDM on oral hypos peri op Mx?

Answer 9

• Cease orals 12/24 pre op
• Monitor BSL 4/24 (treat if 10)
• Supplement w/ insulin for hyperglycemia
• Resume orals when on normal diet

Question 10

Mx TIDM on insulin therapy perioperatively for morning surgery?

Answer 10

• BSL measure 2/24 from 0800
• Give usual dose long acting insulin
• IV dextrose 5% infusion (100ml/h)

Question 11

Mx TIDM on insulin therapy perioperatively for afternoon surgery?

Answer 11

– Light bfast w/ usual dose of long acting insulin and
half of short/intermediate acting insulin
– Monitor blood glucose every 2/24 from adm
– IV 5% dextrose
– Monitor BSL 2 hourly and urinary ketones for 48 hours

Question 12

Mx TIDM on insulin therapy perioperatively for morning surgery?

Answer 12

• BSL measure 2/24 from 0800
• Give usual dose long acting insulin
• IV dextrose 5% infusion (100ml/h)

Question 13

Mx TIDM on insulin therapy perioperatively for afternoon surgery?

Answer 13

– Light bfast w/ usual dose of long acting insulin and
half of short/intermediate acting insulin
– Monitor blood glucose every 2/24 from adm
– IV 5% dextrose
– Monitor BSL 2 hourly and urinary ketones for 48 hours

Question 14

S/C insulin dose BSL 10-14mmol/L and 14.1 - 18?

Answer 14

-4
-6
>18 = 8 and contact endo.