A presentation about Perioperative Management of Diabetes Mellitus

2. INTRODUCTION
• Patients with diabetes have higher
incidence of morbidity and mortality.
• Poor peri-operative glycamic control
increases the risk of adverse outcomes.
• Treatment of post-operative
hyperglycaemia reduces the risk of
adverse outcomes.

3. METABOLIC SEQUELAE IN A
SURGICAL PATIENT
Metabolic effects of starvation:
Period of starvation induces a catabolic state.
It will stimulate secretion of counter- reguletory
hormones.
It can be attenuated in patients with diabetes by infusion
of insulin and glucose(approximately 180g/day).
Metabolic effects of major surgery:
It causes neuroendocrine stress response with release of
counter-regulatory hormones
(epinephrine,glucagon,cortisol and growth hormone)and
of inflammatory cytokines IL-6 and TNF-alpha.

4. Hypoglycaemia-exacerbate the catabolic
effects of surgery.
These neurohormonal changes result in
metabolic abnormalities includes:
Increased insulin resistance.
Decreased peripheral glucose utilisation.
Impaired insulin secretion
Increased gluconeogenesis and glycogenolysis.
Increased lipolysis.
Protein catabolism,leading to
Hyperglycaemia and even ketosis in some

5.  Hypo and hyperglycemia.
 Multiple co-morbidities including microvascular and macrovascular
complications.
 Complex polypharmacy Including misuse of insulin.
 Inappropriate use ofintravenous insulin infusion.
 Management errors when converting from the intravenous insulin infusion to
usual medication.
 Peri-operative infection
 Dehydration(osmotic diuresis)
 Electrolyte imbalance
 Has detrimental effect on CVS and renal func..

6. Factors adversely affecting Diabetes control
perioperatively
• Anxiety
• Starvation
• Infection
• Anaestheticdrugs
• Metabolic response to trauma
• Other drugs:steroids

7. Risk of DM patient during surgery
• Infection
• CV events:
 Silent MI
 Coronary artery disease
• Autonomic neuropathy.

8. Determinents of
management plan
1. Type of DM
2. Treatment,diet,oral antidiabetic drugs,insulin,
3. Metabolic status
4. Vascular status:cardiac,renal,cerebral
5. Surgery:
Emergency or
elective
minor or major
procedure
type of anaesthesia
postoperative oral

9. TARGETS FOR THERAPY
• Target glucose range for the perioperative period should be 80-180mg/dl(4.4-
10mmol/l)[according to ADA]
» In critically ill patient:<180mg/dl
» In stable patient:<140mg/dl
• HbA1c should be <8.5%
• Postpone elective surgery if possible if glycaemic control is poor(HbA1c>=9%)
• For major surgery, if serum glucose is >270mg/dl preoperatively, surgery should be
delayed while rapid control is achieved with IV infusion
• If serum glucose is>400mg/dl, surgery should be postponed and metabolic state
restabized.

10. GOALS OFPERIOPERATIVEGLYCAEMIC
CONTROL
• Strict glycaemic control(81-108)mg/dl:
• increase risk of hypogycaemia
• does not increase outcome.
• High bd glucose>200mg/dl
• Impaired wound healing.

11. CONSENSUS RECOMMENDATIONFOR TARGET
INPATIENT BG CONC.
Pt. Population BG Target Rationale
General surgery Fasting: 90-126mg/dl
Random: <200mg/dl
• Decrease Mortality
• Shorter Hosp. Stay
• Decrease Infection
Cardiac Surgery <150mg/dl • Decrease Mortality
• Decrease Infection
Critically ill Patient <150mg/dl • Decrease Morbidity
• Decrease Mortality
• Shorter Hosp. Stay
Acute Neurologic Disorder 80-140mg/dl Lack Of data consensuson
sp. Target
Ref: ADA, Society Critical Care Medicine

12. Planning admission
• AIM:
 To minimise the fasting period
 To ensure normoglycaemia
 To minimise disruption to the pt”s usual
routine
• Hospital admission is needed at least 7 days
before major surgery to control bd.glucose

13. PRE-OPERATIVE
EVALUATION
 Determine the type of diabetes and its management.
 Ensure that the patient’s diabetes is well controlled.
 Review of medications.
 Ensure that the patient is capable of managing their diabetes
after discharge from hospital.
 Consider the presence of complications of diabetes that might be
adversely affected by or that might adversely impact upon the
outcome of the proposed procedure.
 Identify high-riskpatients requiring criticalcare
management.

14. Pre-0perative Evaluation
To Assess History/Examination Investigation
1.Blood Sugar Control
Hypo/Hyperglycemic
episodes,
Hospitalization,
Medical compliance
BS- F & PP
HbA1C
2. Nephropathy H/O- HTN, Swelling over
body, Recurrent
UTI.
Urine R/M (to exclude
Albuminuria and UTI)
RFT
3.Cardiac Status H/O- Angina/ MI , Swelling of
feet,
Exercise intolerance
ECG, CXR, ECHO
(ECG-less predictive )
4. PVD H/O- Intermittent
Claudication, Blanching of
feet,
Non healing ulcer

15. Contd..
To Assess History/Examination Investigation
5. Retinopathy H/O-Visual disturbances
↑ power of lenses
Fundus Examination
6. ANS Early satiety, abdominal
distension, Anhydrosis,
Impotence, Orthostatic
Syncope
Postural change in BP, HR
variability with exercise,
tachycardia response to
atropine
7. Metabolic &
Electrolyte
H/O- Starvation, Infection
Sign of DKA,
ABG, Urinary Ketone,
S. Electrolyte
8. Airway Scleroderma of Diabetes
Stiff Joint Syndrome
(Prayer sign, Palm Print test)
X-ray cervical spine
AP & Lateral

16. CONTD….
• Prayer Sign:
Patient is unable to approximate
the palmar surface of phalangeal
joints despite of maximal effort.
• Palm Print Test:
Degree of inter-phalyngeal joint
involvement can also be assessed
by scoring the ink impression
made by the palm of dominant
hand.

17. CLINICAL SIGNS OF DIABETIC
AUTONOMIC NEUROPATHY
Hypertension
Painless MI
Orthostatic hypotension
Lack of HR variability
Reduced HR response to atropine & propanolol
Resting tachycardia
Early satiety
Neurogenic bladder
Lack of sweating
Impotence

18. Test for autonomic neuropathy
•Heart rate variability (HRV) in response to:
Deep breathing
Standing
Valsalva maneuver
• BP response to:
1. Standing or passive tilting
2. Valsalva maneuver

19. HbA1-c
• Reflects glycaemic control over last 3 month.
• Check HbA1c 30 days before procedure.
• Set HbA1c goals for elective surgery, no established cut
off point.
• Some set target below HbA1c of 8.5
• Will be based on type of patient
• Young pts without comorbidities are expected to have an
A1C closer to 6.5 (tight control)
– Older patients with multiple comorbidities are allowed to have
A1C closer to 8.5 (loose control)
– General control recommendation from the ADA

20. Patient Education
• Medications to take the day before surgery
• Medications to take the morning of surgery
• Medications to take after returning home or to the
hospital room
• A handnote for the patient may be beneficial including
complete written instructions.

21. BEDSIDE GLUCOSE
MONITORING
• If patient are eating: before meal
• If patient on NPO:4-6 hourly
• Patient on I/V insulin:30 min to 2 hourly
• Peroperatively:hourly
• Postoperatively:every 2 hourly.

22. GENERAL PRINCIPLES
 Diabetes should be well controlled prior to elective surgery.
 Avoid insulin deficiency, and anticipate increased insulin requirements.
 The patient’s diabetes care provider should be involved in the
management of their patient’s diabetes peri-operatively.
 Patients with diabetes should be on the morning list, preferably first on the
list.
 These guidelines may need to be individually modified depending on
the patient’s circumstance.
 Patients should be well hydrated before the procedure
 Withheld Metformin 24 hours before surgery
 In non cardiac general surgery basal insulin+premeal bolus coverage has
been associated with improved glycaemic control compared to traditional
sliding scale regimen.

23. PATIENTSWHO REQUIRE INSULINTHERAPY
• patient with type1 DM must continue basal insulin replacement preoperatively:0.2- 0.3
u/kg/day of a long acting insulin.
• Patients who take both evening and morning doses of insulin should take their usual dose
of evening short-acting insulin, but reduce their intermediate- or long-acting dose by 20%
the night before surgery.
• On the morning of surgery, they should omit their short-acting insulin and reduce the
intermediate- or long-acting dose by 50% (and take this only if the fasting glucose is >120
mg/dl)
• Premixed insulin → reduce their evening dose prior surgery by 20% and reduce their
morning dose of .intermediate acting insulin by 50%
• Patients who on intermediate acting insulin only:
– Usual dose on night before surgery
– Decrease dose by 1/3,if operation is in early morning
– Decrease dose by 1/2,.if operation is in afternoon

24. MAJOR SURGERY(MORNING LIST)
• Maintain the usual insulin doses and diet the day before, and fast
from midnight.
• Omit usual morning insulin (and AHG).
• Commence an insulin-glucose infusion prior to induction of
anaesthesia .
• Measure BGL at least hourly during the intra-operative period.
• Continue the insulin-glucose infusion for at least 24 hours post-
operatively and until the patient is capable of resuming an adequate
oral intake.

25. MAJOR SURGERY(AFTERNOON
LIST)
Give a reduced dose of insulinbefore early breakfast in the
morning.(reduced bolus insulinplus 1/2 day time dose as
intermediate/long actinginsulin)
 BGLs should be monitored closely in the pre-operative ward.
Commence an insulin-glucoseinfusion before induction of
anaesthesia.

26. MINOR SURGERY
Morning list
• Delay the usual morning dose of insulin
provided that the procedure is completed and
the patient is ready to eat just after the
procedure. The patient can then have a late
breakfast after the usual dose of insulin is
given.
• For later procedures, give a reduced dose
of insulin in the morning in the form of
intermediate or long-acting insulin if possible.
• If the BGL remains elevated (>10mmol/l), an I-
G infusion should be commenced.
Afternoon list
• Pre-operative insulin adjustments
similar to that for major surgery in the
afternoon.
• An insulin-glucose infusion may be
necessary if pre-operative insulin
adjustments result in hyperglycemia.
• Overnight admission may be
necessary for those with glycemic
instability or who are unable to
resume their usual diet before
discharge

27. Patients on Oral AHG Medication
(without insulin)
• Stop AHG medication on the day of surgery.
• Restart AHG medication when patients are able to resume
normal meals (except possibly metformin and thiazolidinediones
following cardiac surgery).
• Commence an I-G infusion if the BGL >10
mmol/L(180mg/dl); if surgery is prolonged and complicated;
or if the patient is usually treated with more than one oral AHG
agent.
• Subcutaneous insulin may be required post-operatively.

28. Patients on Diet Alone
• For patients whose diabetes is maintained on diet alone and
who are well controlled (HbA1c < 6.5%), no specific therapy is
required, but more frequent BGL monitoring during the peri-
operative period is recommended. During the procedure, BGLs
should be checked hourly.
• BGL remains above 10 mmol/L (180mg/dl) in the pre- or peri-
operative period, an I-G infusion should be commenced and
continued until they resume eating.
• If the patient does not become hyperglycemic following surgery,
the patients‟ BGL should be monitored every 4 – 6 hours until
they resume their usual meals.
• Patients who are hyperglycemic peri- or post-operatively may
require supplemental insulin and/or the initiation of specific AHG

29. Peroperative period
• Glucose levelmustbe maintainedin between140-180mg/dl
• Strict control(80-110mg/dl)has chance todevelopfatal
hypoglycaemia.
• BGL should be monitoredhourly.
• Switching toI/Vinsulin maybeappropriate dependingon the
type ofsurgery
• Twomainmethodsofinsulin administration:
 Insulindrip/infusion(VRIII)
 Insulinin combination withglucose & or potassium(GIK)

30. Peroperative
 Insulin drip- short acting insulins preferred
 99ml of0.9%N/S +1ml (100unit) insulin (1 unit/1ml) OR
 250ml of 0.9%N/S+ 25unit insulin (0.1 unit/ml) OR
 250ml 0.9% N/S+ 250U insulin (1U/ml)
 Infusion rate(insulin unit perhour)=BG conc.(mg/dl)/150

31. Peroperative Insulin Drip
Blood glucose(mg/dl) Insulin(units/hr)
<90 0
90-180 1
180-270 2
270-360 3
>360 6( monitoring, urine for ketones)

32. GIK REGIMEN
• 1000ml 5% glucose (50gm) + 20 mEq of potassium + 15 U insulin.
• 100ml/hour=1600 drops/60 min=26 d/min. Insulin increment may be
needed if blood glucose>180mg%
• Potassium <= 3 mEq/l---20 mEq KCL
• Potassium 3-5 mEq/l----10 mEq KCL,if renal function is normal.

33. • Insulin-glucose infusionsshouldbe continueduntilthe patientscan resume anadequatediet.(or
atleast24 hrs)
• Postoperatively,assoonasthe patientstartseating,thosewho arenormallytreatedwithOHA may
need S/C insulin fora fewdays.
• Changing over to regulerdosing: Overlapthe IV infusionforatleasttwomorehourswiththe
subcutaneousinsulin priortodiscontinuingtheIV insulin.
• The startingdoseofbasalinsulin shouldbe50%to80% ofthepriorIV insulin totaldailydose,if
stableglycemic controlhadbeen achived withIV insulin.
• Hyperglycemia detected post-operatively in patients not previously known to havediabetes
should be managed as if diabetes was present, and the diagnosis of diabetesreconsidered
oncethepatienthasrecovered fromtheirsurgery.

34. SLIDING SCALE REGIMEN
S/C
Glucose in mg/dl Regular Insulin S/C
150-200 2 unit
201-250 4 unit
251-300 6 unit
301-350 8 unit

35. RATEOF INSULIN INFUSION
Bedside capillary glucose (mmol/L) Initial rate of insulin infusion
(units/hour)
<4.0 0.5
(0.0 if a long acting background insulin has
been continued )
4.1-7.0 1
7.1-9.0 2
9.1-11.0 3
11.1-14.0 4
14.1-17.0 5
17.1-20 6
>20 Seek diabetes term of medical advice

36. FLUID MANAGEMENT
Aims of fluid management:
• Provide glucose as substrate to prevent proteolysis, lipolysis and
ketogenesis.
• Optimise intravascular volume status.
• Maintain serum electrolytes within the normal
ranges.

37. Intravenous Fluids
1. Dextrose saline / normal saline is used if blood
pressure is low or normal.
2. If there is hypertension half normal saline or 5 %
dextrose is given.
3. For normal metabolism 50 gm glucose is required
every 8 hours for energy and to avoid ketosis, to meet
this demand at least 1000 cc 5 % glucose every 8 h
will be required.
4. In situations requiring fluid restriction 10 % dextrose
can be infused instead of 5 % with double the dose of
insulin.

38. CONTD…
 Very occasionally, the patient may develop hyponatremia without signs of fluid or
salt overload, In such cases 0.45% saline is replaced by 0.9% saline with dextrose
and potassium.
 hypovolemia/hypotension – treat with crystalloids.
• 0.9% Normal saline
• Hartman solution( Gluconeogenic since lactate/acetate) not contraindicated
in diabetic(Interfere with glycemic control )
 Recommendations *
• Hartmann’s solution should be used in preference to 0.9% saline.
• Glucose containing solutions should be avoided unless the blood glucose is low.
•1) Management of adults with diabetes undergoing surgery and elective procedures: improving standards- NHS(National
institute for health and clinical excellence ) APRIL 2011.
•2) Guidelines for intravenous fluid therapy for adult surgical patients(GIFTASUP )MAR 2011.

40. PREOP FASTING
 Atleast 6 hrs for solid foods.
 Patients with gastroparesis , 12 hrs may be needed. Such patients
are given H2 receptor blocker(Ranitidine) and prokinetics
(metoclopromide).
 When fasting exceeds 8-10 hrs then insulin-glucose infusion has to
be started to prevent catabolism.
Gastric emptying
(1)- in DM patients
(2)- after Metoclopromide
(3)- normal person

41.  DM affects oxygen transport by causing glucose
binding to Hb.
 Chronic kidney disease is asymptomatic in
diabetic and usually advanced.
 Autonomic dysfunction :
• Exacerated Hypotension
• Risk of hypothermia
• Sympathetic response are blunted
• Silent MI

42.  Inhibits intestinal motility, delayed gastric emtying.
 Difficult Airway-
• restricted joint movement( atlanto-occipital)
• Obesity
 Therapy related-
• Sulphonylureas - hypoglycemia
• Metformin - lactic acidosis
• Incretins & amylin - delays gastric emptyig , nausea

43.  Propofol – lipid loading lead to impaired metobolism in DM, decreased lipid clearance.
Its of more concern when given in infusion.
 Etomidate -  decreases adrenal steroidogenesis  decreased glycaemic response
to surgery.
 Ketamine- may cause significant hyperglycemia
 Midazolam –(high doses/infusion)
 decreases ACTH & Cortisol  decreased sympathoadrenal
stimulation  decreased glycemic response to surgery.
 Alpha-2 adrenergic agonist – decreases sympathetic outflow from hypothalamus,
decreases ACTH. improves glycemic control.

44. Contd…
 Opiods – (high dose opiod anaesthesia) – offers hemodynamic, metabolic,
hormonal stability . Blocks entire sympathetic nervous system & Hypothalamo-
pituitary axis.
 Inhalationals – (in vitro) halothane , isoflurane , enflurane inhibit the insulin
response to glucose in reversible and dose dependent manner.
 Dexamethasone- PONV, but increases blood sugar.
 NSAIDS 
 Aggravate gastritis(when on aspirin).
 Aggravate renal dysfunction.

45. ADVANTAGES
 Regional anaesthesia blunts the
increases in catecholamines
,cortisol, glucagon, and glucose.
 Metabolic effects of anaesthetic
agents avoided
 An awake patient – hypoglycaemia
readily detectable.
 Decreased chance of Aspiration,
PONV and Thromboembolism.
 Rapid return to diet and Sc
insulin/OHA
DISADVANTAGES
 If autonomic neuropathy is present,
profound hypotension may occur.
 Infections and vascular
complications may be increased
(epidural abscesses are more
common in diabetics)
 Medicolegal concern of risk of
nerve injuries and higher risk of
ischaemic injury due to use of
adrenaline with LA

46. ADVANTAGES
– High dose opiate technique may
be useful to block the entire
sympathetic nervous system and
the hypothalamic pituitary axis.
– Better control of blood pressure in
patients with autonomic
neuropathy.
DISADVANTAGES
 May have difficult airway. (“Stiff-
joint syndrome”)
 Full stomach due to gastroparesis.
 Controlled ventilation is needed as
patients with autonomic
neuropathy may have impaired
ventilatory control.
 Aggravated haemodynamic
response to intubation.
 It may masks the symptoms of
hypoglycaemia

48. PREGNANCY
 Pregnancy is a diabetogenic state. As pregnancy advances insulin resistance
increases.
 Hyperglycemia during pregnancy has both maternal and fetal complications &
adverse outcome.
 Challenges – Altered maternal physiology & disease associated with pregnancy.
• Maternal hyperglycaemia :
 Increases the risk of neonatal jaundice.
 The risk of neonatal brain damage, and
 Fetal acidosis if the fetus becomes hypoxic

49. GDM-DIAGNOSIS

50.  Need tighter control.
• Premeal- 60-90mg/dl.
1 hr pp - < 140mg/dl.
2 hr pp - < 120mg/dl.
 More prone for hypoglycemia /hyperglycemia
 DKA – usually occurs during 2nd/ 3rd trimester, even develops with
low glucose value of 200mg/dl.

51.  HYPERGLYCEMIC :
• DKA
• hyperosmolar hyperglycaemic state.
 HYPOGLYCEMIC:

52. DKA
BG≥ 250 mg/dl
Acidosis-pH<7.3
Serum HCO3<15meq/l
Serum Ketone>7meq/l
Osmolarity-300-320
K+ ↑/ ↓
Urine may be positive for
ketone body.
↑ anion gap metabolic acidosis
↑ serum amylase

53.  Insulin replacement-
0.1U/kg bolus followed by 0.1U/kg/hr and if BG does not ↓ by 10%-repeat
the loading dose –if still no response –double the infusion dose in every 2 hr.
 Fluids:
0.9% NS-1-2 ltr in 1st hr
0.45%NS-2-5 ml/kg/hr
0.45%NS - when the BG< 250 mg/dl
& 5%DS
 Electrolyte:
20-30meq of K+/ hr
Replace phosphate when, <1mg/dl

54. Insulin replacement:
Less insulin require as compared to DKA 15 U i.v bolus then 0.1 U/kg/
hr
Fluids: Reqirement is more than DKA
0.9% NS-2-3 ltr in 2-3 hr
0.45%NS-2-5 ml/kg/hr
0.45%NS - when the BG< 250 mg/dl
& 5%DS
Electrolyte:
20-30meq of K+/hr concurrently

55. Blood sugar < 70 mg/dl.
Clinically Significant Hypoglycaemia
<54mg/dl.
Symptoms due to Adrenergic excess and
Neuroglycopenia.
Sweating, tachycardia/bradycardia ,
tremers, hypotension, dizziness, irritability,
seizures, or coma.
Stop insulin & give dextrose 20-30 ml
50%dextrose
HYPOGLYCEMIA

56. DM & EMERGENCY SURGERY
 Usually Infected
 Usually Uncontrolled
 Dehydrated
 Metabolic decompensated
 Increased resistance to insulin
 More Chances of acute Hyperglycemic complication

57.  Little time for stabilisation of patients ,but if 2-3 hr available
• correction of fluid and electrolyte imbalance .
• Correct hyperglycemia.(start I-G infusion if sugar > 180mg/dl)*
• Treat acidosis.
• Avoid hypoglycemia.
 Surgery should not be delayed in an attempt to eliminate
ketoacidosis completely if the underlying condition will lead to
further metabolic deterioration.
•Management of adults with diabetes undergoing surgery and elective procedures: improving standards-
•NHS(National institute for health and clinical excellence ) APRIL 2011

58. Contd…
 If enough time is not available – correction of hydration status ,
electrolytes, acidosis, blood sugar should be started & should achieve
an improving metabolic trend before starting anaesthesia.
 Likelyhood of intra-op hypotension and arrhythmia is more particularly
if pt has pre-op acidosis or hypokalemia.
 Intra-op sugar to be monitored more frequently.
 Atleast hourly.
 LSCS – every 30 min.*
•Management of adults with diabetes undergoing surgery and elective procedures: improving standards-
•NHS(National institute for health and clinical excellence ) APRIL 2011

59. FLUIDMANAGEMENT
(IN PATIENTS REQUIRING VRIII)

60. CONTD…
 Since no randomised trails demonstrate superiority of any
fluid, and until there are clincal studies to verify safest
solution
 THE RECOMMENDATION IS
 0.45%SALINE,5%DEXTROSE&0.15%KCL as first choice.
FOR PATIENTS NOT REQ VRIII
 Ringers lactate/acetate, Hartmanns solution is used.
 0.9%saline hyperchloremic acidosis.
•Management of adults with diabetes undergoing surgery and elective procedures: improving standards-
•NHS(National institute for health and clinical excellence ) APRIL 2011