Perioperative glycaemic control Flashcards
How does diabetes impact surgery outcomes?
Patients with diabetes undergoing surgery have greater
- Complication rates
- Morbidity and mortality rates
- Length of hospitalisation
What is the diagnostic criteria for T1DM in adults?
Hyperglycaemia presentation; plus one or more of
- Ketosis
- Rapid weight loss
- Age of onset <50y
- BMI <25
- PMH or FHx of autoimmune disease
When should T1DM be suspected in a child or young person?
Hyperglycaemia presentation and characteristic features of
- Polyuria
- Polydipsia
- Weight loss
- Excessive tiredness
Outline the characteristics of diabetic ketoacidosis
- Acidosis (pH <7.3)
- Hyperglycaemia
- Elevated ketones
Give three presenting features suggestive of T2DM
- Hyperglycaemia
- Thirst; polyuria; blurred vision; weight loss; recurrent infection; fatigue
- Not usually severe and may be absent
- Risk factors for T2DM
- Evidence of insulin resistance: acanthosis nigricans
- No additional features of T1DM
- No features of monogenic diabetes; secondary diabetes; trauma; drug treatment; or pancreatic surgery
What investigation usually confirms a diagnosis of T2DM in adults?
What is a positive test result?
HbA1c of 48 mmol/mol (6.5%) or more
Give three perioperative risks specifically present in diabetic patients
- Hypoglycaemia, hyperglycaemia, or ketoacidosis
- Specific complications of diabetes
- At risk foot
- Renal impairment
- Cardiac disease
- Increased susceptibility to infection
- Poor wound healing
- Increased susceptibility to skin pressure necrosis
Name 3 specific complications of diabetes to be included in a surgical referral
- At risk foot
- Renal impairment
- Cardiac disease
What is considered as optimised glycaemic control for elective surgery?
Pre-operative HbA1c <69 (8.5%) mmol/mol
What is the preoperative consequence of poorly controlled diabetes?
If HbA1c is 69 mmol/mol or greater, elective surgery should be delayed until control is improved preoperatively.
What preoperative investigations should be ordered to assess diabetic co-morbidities?
- Renal function
- Albumin:Creatinine ratio (ACR): urine test
- Serum creatinine for eGFR
- ECG
Which diabetic patients are indicated for perioperative variable-rate IV insulin infusion (VRIII)?
- T1DM missing more than one meal
- T1DM not receiving background insulin
- T2DM missing >1 meal + develops hyperglycaemia
- Poorly controlled (HbA1c >69 mmol/mol [>8.5%])
- Emergency surgery
What is the target perioperative CBG level for diabetic patients?
When should perioperative CBG be assessed?
Fasting CBG 6-10 mmol/L
CBG monitored hourly during the procedure and immediately post-op
Define brittle diabetes mellitus
- Hard to control T1DM
- Frequent, extreme swings in blood glucose.
What preoperative measures should be taken for diabetic patients?
- Clarify if patient is oral-controlled, insulin-dependent, or brittle insulin dependent
- Risk of perioperative complications increases as more difficult to control
- Diabetes should be first on the operating list to minimise the fasting period
