![At least three of the following
Fasting plasma glucose ≥ 110 mg/dl
Abdominal obesity (waist girth > 40 [in men], 35 [in women])
Serum triglycerides ≥ 150mg/dl
Serum HDL cholesterol < 40 mg/dl (men), <50 (women)
BP ≥ 130/85 mm Hg
Insulin-resistant syndrome is a constellation of clinical &
biochemical characteristics frequently seen in pt with or at risk
of type 2 diabetes.](https://image.slidesharecdn.com/surgeryindiabetes-nesar-180726095044/75/Surgery-in-diabetes-patients-Dr-nesar-Ahmad-13-2048.jpg)
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Surgery in diabetes patients Dr nesar Ahmad
This document discusses diabetes, its classification, signs and symptoms, and management in surgical patients. It notes that diabetes is a chronic condition characterized by high blood glucose resulting from insulin deficiency or resistance. It also discusses the increased risks that diabetic patients face during surgery due to hormonal and metabolic responses to trauma. The document provides guidelines for evaluating, monitoring, and controlling blood glucose levels in diabetic patients before, during, and after surgical procedures.
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Surgery in diabetes patients Dr nesar Ahmad
- 1. PRESENTED BY- DR. NESARAHMAD MODERATOR- DR. SIMEEN USMANI D/O JARAHAT, AKTC, AMU
- 2. Diabetes Diabetes isa clinical syndrome of hyperglycaemia with glycosuria resulting from insulin deficiency or intolerance It is a chronic disorder of carbohydrate, fat and protein metabolism. Approximately 10% of patients admitted to hospital have diabetes Globally it is estimated that 451 million people had diabetes in 2017 in which 72 million cases of diabetes recorded in India 50% of all diabetic patients present for surgery during their lifetime
- 3. •Perioperative morbidity andmortality are greater in diabetic than in non-diabetic patients •Diabetic patients have up to 50% higher peri-operative mortality than in non-diabetic patients •Globally diabetes caused 5 million deaths in 2017 •Someone in the world dies from complications associated with diabetes every 10 seconds •Diabetics have health expenditures that are 2.3 times higher than non-diabetics.
- 4. Etiological Classification ofDM I. Type – 1 IDDM (insulin dependent diabetes mellitus) Its Sub-divided into: A. Immune Mediated (Islet cell antibodies) B. Idiopathic (No antibodies) II. Type – 2 NIDDM (non insulin dependent diabetes mellitus) III. Other specific types of diabetes: A. Genetic defect of beta cell function characterised by mutations B. Genetic defects in insulin action C. Diseases of the exocrine pancreas- pancreatitis, neoplasia, cystic fibrosis, hemochromatosis etc. D. Endocrinopathies- Acromegaly, Cushing’s syndrome, Phaeochromo -cytoma, hyperthyroidism E. Drug Induced Diabetes - Due to steroids ,Thiazides, thyroid hormone, phenytoin, etc. F. Infections- rubella, cytomegalovirus etc. G. Other Genetic Syndrome associated with diabetes i.e. Lipodystrophies, muscular dystrophy, Klinefelter’s syndrome,Turner’s Syndrome, Down’s Syndrome, etc. IV. Gestational diabetes mellitus
- 5. Type 1 DiabetesMellitus (Insulin Dependent) Type 1 diabetes or Insulin Dependent Diabetes Mellitus is also known as juvenile diabetes. It usually occurs in childhood or early adulthood i.e. usually begins below the age of 30 yrs. b/w 5-10% of individuals develop type 1 DM after age 30. It manifests itself in two ways: Classic Triad Of Type 1 Diabetes Mellitus : Polydipsia, Polyuria and Polyphagia. Ketoacidosis: Patient present with Diabetic Ketoacidosis following an acute infection or surgery as an first episode without any apparent cause. In severe cases, patient may develop mental apathy, confusion and may lapse into coma.
- 6. Polygenic disorderthought to be of auto immune aetiology Results in destruction of β cells in the Islets of Langerhans in the Pancreas, with complete or near- total insulin deficiency Endogenous insulin is required to maintain plasma glucose levels to within physiological levels
- 7. Type 2 DiabetesMellitus (Insulin Resistance) Type 2 diabetes mellitus or Non insulin dependent diabetes mellitus, usually begins after the age of 40 years and 60 % of the patients are obese. However young patients of type 2DM are also seen nowadays. Type 2 DM occurs with intact beta cells of islets of langerhans, but there is peripheral tissue resistance to insulin. There may be some decrease in insulin production or a hyper insulin state. Hyperglycaemia resulting from reduced insulin secretion and peripheral insulin resistance These patients usually does not develop Ketoacidosis.
- 8. • The plasmainsulin levels are normal to high. • Glucagon levels are high but resistant to insulin. • T2DM leads to many health problems including cardiovascular disease, stroke, blindness, kidney failure, neuropathy, impotency, depression, cognitive decline and mortality risk from certain forms of cancer. • Premature death from T2DM is increased by as much as 80 percent and life expectancy is reduced by 12 to 14 years • Depending on severity, may be controlled with: - Lifestyle intervention (Appropriate diet and exercise to lose weight) - oral hypoglycaemics - insulin
- 9. Gestational Diabetes Mellitus GDM is hyperglycaemia with blood glucose values above normal but below those diagnostic of diabetes, occuring during pregnancy Women with GDM are at an increased risk of complications during pregnancy and at delivery They and their children are also at increased risk of type 2 diabetes in the future It is diagnosed through prenatal screening
- 10. Fasting Postprandial(2hr GTT) Normal <100(5.6) <140(7.8) Diabetes Mellitus ≥126 >200 Impaired Fasting Glycaemia 100 - 125(5.6-6.9) <140(7.8) Impaired Glucose Tolerance <126(7.0) ≥140 & 200(7.8 & 11.1) Condition Venous Plasma Glucose Concentration in mg/dl(mmol/L)
- 11. 1. Classic Symtomsof diabetes plus random plasma glucose level ≥ 200 mg/dL (≥ 11.1 mmol/L) Random is defined as any time of day without regard to time since last meal. 2. Fasting plasma glucose level ≥ 126 mg/dL (≥ 7.0 mmol/L) Fasting is define as no caloric intake for at least 8 hrs 3. Two-hour plasma glucose level ≥ 200 mg/dL (≥ 11.1 mmol/L)
- 12. METABOLIC SYNDROME(syndrome x)AND RISK FACTORS ASSOCIATED WITH DIABETES MELLITUS: WHO DIAGNOSTIC CRITERION - 1.CONTROL OBESITY BMI>30KG/METRE SQUARE WAIST /HIP RATIO MEN>0.90 WOMEN>0.85 2. TRIGLYCERIDE >150mg/dl 3.HDL CHOLESTEROL Men<35mg/dl Women<39mg/dl 4. Fasting Glucose >110mg/dl 5. Microalbuminurea Urinary albumin excretion rate >/ =20 mu gm/min DIAGNOSIS IS MADE WHEN 3 OR MORE OF THESE RISK FACTORS ARE PRESENT
- 13. At least threeof the following Fasting plasma glucose ≥ 110 mg/dl Abdominal obesity (waist girth > 40 [in men], 35 [in women]) Serum triglycerides ≥ 150mg/dl Serum HDL cholesterol < 40 mg/dl (men), <50 (women) BP ≥ 130/85 mm Hg Insulin-resistant syndrome is a constellation of clinical & biochemical characteristics frequently seen in pt with or at risk of type 2 diabetes.
- 14. Diabetes and Surgery Surgery is a form of physical trauma It results in catabolic stress and secretion of counter-regulatory hormones (including catecholamines & cortisol) in both normal and diabetic patients, resulting in increased glycogenolysis, gluconeogenesis, lipolysis, proteolysis and insulin resistance. Starvation exacerbates this process by increasing lipolysis. 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
- 15. Factors Adversely Affecting DiabeticControl Perioperatively Anxiety Starvation Anaesthetic drugs e.g. Opiates, benzodiazepine Infection Metabolic response to trauma Diseases underlying need for surgery Other drugs e.g. steroids
- 16. Metabolic & HormonalResponses to Surgery Hormonal Secretion of stress hormones Cortisol Catecholamines Glucagon Growth Hormone Cytokines Relative decrease in insulin secretion Peripheral insulin resistance Metabolic Increased gluconeogenesis and glycogenolysis Hyperglycaemia Lipolysis Protein breakdown
- 18. Metabolic Response toSurgery and Diabetes Hypoglycaemia When the plasma glucose concentration is <55 mg/dl (<3.0 mmol/L) with symptoms of hypoglycemia Symptoms include behavioral changes, confusion, fatigue, seizure loss of consciousness . If hypoglycaemia is severe and prolonged death may occur. 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 Can lead to irreversible neurological deficits Dangerous in anaesthetised or neuropathic patient as the warning signs may be absent Management Give i.v dextrose (25 gm) and monitor glucose levels
- 19. Metabolic Response toSurgery and Diabetes Hyperglycaemia 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 dehydrated 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 Management Frequently measure blood glucose and administer insulin
- 20. Metabolic Response toSurgery and Diabetes Ketoacidosis Any patient who is in a severe catabolic state and has an insulin deficiency (absolute or relative) can decompensate into keto-acidosis Most common in type 1 patients Increased risk postoperatively, often precipitated by the stress response, infection, MI, failure to continue insulin therapy. characterised by hyperglycaemia, hyperosmolarity, dehydration (may lead to shock and hypotension) and excess ketone body production resulting in metabolic acidosis.
- 21. Metabolic Response toSurgery and Diabetes Management restore intravascular volume eliminate ketonaemia control blood glucose replace electrolytes monitor glucose and ketone levels
- 22. Underlying Cardiac Complicationsof Diabetes and Surgery Cardiovascular problems frequently present in long standing diabetics Ischaemic Heart Disease Coronary artery disease Hypertension Diabetic patients must be considered as being at high risk of MI Induction of anaesthesia and tracheal intubation can lead to a reduction in cardiac output Management Most cardiac and antihypertensive drugs should be continued throughout the perioperative period except, aspirin, diuretics and anticoagulants History to determine effort tolerance, clinical examination for cardiac failure and an electrocardiogram in all patients.
- 23. Underlying Renal Complicationsof Diabetes and Surgery Renal Renal dysfunction Intrinsic renal disease including glomerulosclerosis and renal papillary necrosis enhance the risk of acute renal failure perioperatively Proteinuria is an early manifestation Dialysis should optimally be done the day before surgery. Urinary infection Management Urea and electrolyte determination. Dipstix urinalysis for proteinuria
- 24. Underlying Nervous SystemComplications of Diabetes and Surgery Nervous System Counter-regulatory response to hypoglycaemia Peripheral neuropathy with an increased susceptibility to iatrogenic nerve injuries Cardiac Autonomic Neuropathy Management History of postural dizziness, post gustatory sweating, nocturnal diarrhoea and impotence. Careful documentation of peripheral sensation
- 25. Underlying Immune Complicationsof Diabetes and Surgery Immune and infectious risk Diabetics are susceptible to infection and have delayed wound healing Hyperglycaemia facilitates proliferation of bacteria and fungi depresses the immune system management Proteolysis and decreased amino acid transport retards wound healing. Loss of phagocytic function increases the risks of post-operative infection Management Need very strict sterile techniques and need to assess risk/benefit ratio for procedures e.g catheterisation
- 26. Underlying Gastrointestinal and OphthalmologicalComplications of Diabetes and Surgery Gastrointestinal Gastroparesis Management History of early satiety and reflux H2 blocker and metoclopramide Ophthalmology Cataracts, glaucoma and retinopathy decrease visual acuity and increase the unpleasantness of the perioperative period Management Increase the amount of explanation and reassurance to the patient.
- 27. Principles of ManagingDiabetics During Surgery Diabetic management depends upon: the nature of the diabetes and its treatment (insulin-dependent or non- insulin-dependent) the magnitude of the surgery contemplated, in particular duration of fasting the time available for improving control of the diabetes preoperatively if necessary Management of preoperative insulin therapy depends on baseline blood glucose, level of diabetic control, severity of illness and the proposed surgical procedure However, aims for all diabetic patients are: No excess mortality No increase in post-op complications Normal wound healing No increase in duration of hospitalisation No hypoglycaemia, hyperglycaemia or ketoacidosis
- 28. Pre-operative Assessment ofPatient with Diabetes History : duration of diabetes, control & organ effects, dietary intake, associated co-morbidities with medications, h/o previous surgeries, anaesthesia and drug allergies. Physical Exam : signs & symptoms of autonomic dysfunction, cardiac ds, renal ds, retinal involvement • Lab Investigations : Fasting PG, PPPG, B.Urea, Creatinine, Electrolytes, Urine Albumin/ Creatinine ratio, HbA1c (to assess how well controlled diabetes is) Cardiac evaluation : Chest X Ray & Echocardiography, TMT depending upon clinical situation, optimise blood pressure
- 29. Glycemic Targets forSurgical Patient Too tight control of blood sugar to be avoided Non-critically ill patient : < 140 mg/dl preprandially & <180mg/dl postprandially Critically ill patients : 110mg/dl preprandially & < 180 mg/dl postprandially HbA1c should be 48-59 mg/dl or 6.5-7.5mmol/L in a well- controlled diabetic patient
- 30. General Guidelines Patients onOAD with good glyc control for minor surgery: can continue usual medications Metformin should be stopped 24-48 hrs prior to surgery & restarted only after checking RFT post op. Long acting Sulfonylureas (SU) to be substituted with short acting SU, 5 days prior to surgery to prevent hypoglycemia Patient need to be admitted on day of surgey Place first on morning operating list if possible cont...
- 31. Indications of startingInsulin preoperatively : Poor glycemic control Infection Nil oral instructions Non healing wounds Other co-morbid conditions
- 32. Patients on OADwith poor glycemic control : Swich over to Insulin Admit 2 to 3 days prior to surgery Patients on insulin to be continued on insulin, may need dose adjustment to achieve glycemic targets
- 33. Intraoperative Management Bestto post surgery in morning (First on the OT list) Morning dose of OAD is omitted as patient will not have break fast At the start of surgery IV insulin & glucose is given either through separate lines or as a combined GIK (Glucose- Insulin-Potassium infusion) GIK is simpler but any changes in dosage necessitates change of entire infusion. Separate insulin and glucose infusion is better and needs close blood sugar monitoring. Cont...
- 34. Cont... Blood glucoseshould be monitored hourly during & immediately after procedure & changes in infusion rate are made as needed. Once patient is allowed to take orally, Subcutaneous insulin is started IV Fluids During Surgery : 1. Dextrose saline or normal saline if BP is low or normal 2. If IVF restriction is advised 10% Dextrose instead of 5% Dextrose 3. Avoid Ringer Lactate solution
- 35. Management Protocols forElective Surgery in Patients with Diabetes Before and preoperative Surgery Post-operative PATIENTS NOT ON INSULIN Minor surgery and good glycemic control Replace any long-acting SU admit day before Surgery Operate in morning omit breakfast and oral agents avoid glucose containing infusions monitor blood glucose 2- hourly Monitor blood glucose restart oral agents with first post op meal
- 36. Management Protocols forElective Surgery in Patients with Diabetes Before and preoperative Surgery Post-operative PATIENTS NOT ON INSULIN Major Surgery and/ or poor glycemic control Admit 2-3 days before surgery stablize control with insulin Operate in morning Start IV insulin and glucose Omit breakfast & insulin Monitor blood glucose hourly Monitor blood glucose Transfer to SC insulin once oral intake restarted. Return to oral agents when control stable
- 37. Management Protocols forElective Surgery in Patients with Diabetes Before and preoperative Surgery Postoperative PATIENTS TREATED ON INSULIN Good/ poor control Admit 2-3 days before surgery Stablize control if necessary Operate in morning Start IV insulin and glucose Omit breakfast & insulin Monitor blood glucose hourly Monitor blood glucose Restart SC insulin before first postoperative meal discontinue iv insulin 30- 60 min later
- 38. 1 ml perhour Intra-operative Insulin Infusion
- 39.
- 40. Adjusting Insulin Infusionrate with hourly blood sugar levels Blood Glucose (mg/dl) Insulin infusion rate <80 Glucose at 5-10 gm/hr, recheck after 15 m 80 - 140 Decrease infusion by 0.4 U/ hr 141 - 180 No change 181 - 220 Increase by 0.4 U/hr 221 - 250 Increase by 0.6 U/hr 251 - 300 Increase by 0.8 U/hr > 300 Increase by 1 U/hr
- 41. Post operative management Patients who need to continue fasting after surgery should be maintained on IV Insulin and fluids until they are able to eat and drink IV fluids during prolonged insulin infusion should include saline and potassium supplimentation UK guidelines recommend use of dextrose/saline (0.45% saline with 5% dextrose & 0.15% potassium chloride). When patient’s usual treatment has been reinstated, care must be taken to continue to control the blood glucose , ideally b/w 4-10 mmol/L ( 70-180mg/dl). Patients normally controlled on tablets may require temporary subcutaneous insulin treatment until the increased stress of surgery, wound healing or infection has resolved 41
- 42.