Management of Diabetes in Surgery

Posted by e-Medical PPT Wednesday, September 21, 2011
Diabetes is a metabolic disorder resulting from insulin deficiency or intolerance
Associated with acute and long term systemic problems
Diagnosed by a random plasma glucose >11.1mmol/l and a fasting glucose>7.0mmol/l (WHO criteria)
The two most common forms of diabetes are Insulin Dependant Diabetes Mellitus (Type 1) and Non Insulin Dependant Diabetes Mellitus (Type 2)

Type 1 Diabetes Mellitus
Polygenic disorder thought to  be of auto immune  aetiology
Results in destruction of β cells in the Islets of Langerhans in the Pancreas, with subsequent insulin deficiency
Young onset
0.4% prevalence
Endogenous insulin is required to maintain plasma glucose levels to within physiological levels

Type 2 Diabetes Mellitus
Hypoglycaemia resulting from reduced insulin secretion and peripheral insulin resistance
Some genetic concordance
Older onset, associated with central obesity
Depending on severity, may be controlled with:
diet and exercise to lose weight
oral hypoglycaemics

Diabetes and Surgery
Surgery is a form of physical trauma
It results in catabolism, increased metabolic rate, increased fat and protein breakdown, glucose intolerance and starvation.
In a diabetic patient, the pre existing metabolic disturbances are exacerbated by surgery
The type of diabetes, amount of insulin dose, diet or oral hypoglycaemic agents must be considered as this will change the overall management plan
The risk of significant end-organ damage increases with the duration of diabetes, although the quality of glucose control is more important than the absolute time

Factors Adversely Affecting Diabetic Control Perioperatively
Anaesthetic drugs
Metabolic response to trauma
Diseases underlying need  for surgery
Other drugs e.g. steroids

Metabolic Response to Surgery and Diabetes
May develop perioperatively due to the residual effects of preoperative long acting oral hypoglycaemic agents or insulin.
Exacerbated by preoperative fast or insufficient glucose administration
Counter-regulatory mechanisms may be defective because of autonomic dysfunction
Can lead to irreversible neurological deficits
Dangerous in anaesthetised or neuropathic patient as the warning signs may be absent

Give i.v dextrose and monitor glucose levels

Glucagon, cortisol and adrenaline secretion as part of the neuroendocrine response to trauma, combined with iatrogenic insulin deficiency or glucose overadministration may result in hyperglycaemia
Causes osmotic diuresis, making volume status difficult to determine and risking profound dehydration and organ hypoperfusion, and increased risk of UTI
osmotic diuresis, delayed wound healing, exacerbation of brain, spinal cord and renal damage by ischaemia
Results in hyperosmolality with hyperviscocity, thrombogenesis and cerebral oedema

Frequently measure blood glucose and administer insulin..

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