Preoperative, peroperative and postoperative Management of Diabetes by Dr Shahjada Selim.

1. PerioperativePerioperative
Management ofManagement of
DiabetesDiabetes
Dr Shahjada Selim
MBBS MD (EM)
Registrar (Medicine)
ShSMCH

2. Importance of controllingImportance of controlling
Diabetes in SurgeryDiabetes in Surgery
It is critical to control diabetes before,
during and after surgery (pre, per and
postoperatively) to improve outcome of
surgery or to prevent complications.

3. Hyperglycemia during surgery may
produce:
1. Dehydration (Osmotic Diuresis)
2. Electrolyte imbalance
3. Impair wound healing
4. Increase infection rate
5. Chance to develop keto acidosis
6. Has detrimental effect on CVS and renal
function.
About 25% diabetic patient need surgery.

4. 44
 Hyperglycemia leads to impaired woundHyperglycemia leads to impaired wound
healing and deficient formation ofhealing and deficient formation of
granulation tissue.granulation tissue.
 The chemotactic, phagocytic, andThe chemotactic, phagocytic, and
bactericidal activity of the neutrophils arebactericidal activity of the neutrophils are
deficient.deficient.
 there is impaired humoral host defensethere is impaired humoral host defense
mechanism and abnormal complementmechanism and abnormal complement
function.function.
As..As..

5. 55
Metabolic sequelae in surgical patientMetabolic sequelae in surgical patient
 Increased glycogenolysis,Increased glycogenolysis,
gluconeogenesis andgluconeogenesis and
hyperglycemia.hyperglycemia.

6. 66
……………….Metabolic sequelae in surgical patient.Metabolic sequelae in surgical patient
 Decreased glucose utilization due to-Decreased glucose utilization due to-
 Lipolysis with increased FFALipolysis with increased FFA
productionproduction
 Protein breakdownProtein breakdown
 nitrogen lossnitrogen loss
 urea productionurea production
 sodium retension & potassiumsodium retension & potassium
execretion and alteration of waterexecretion and alteration of water
metabolism ( increased ADH andmetabolism ( increased ADH and
increased aldosterone secretion )increased aldosterone secretion )

7. 77
Determinants of ManagementDeterminants of Management
Plan in DiabetesPlan in Diabetes
 Type of DMType of DM
 DietDiet
 Drugs: Insulin or OHADrugs: Insulin or OHA
 Metabolic statusMetabolic status
 Vascular status: cardiac, renal,Vascular status: cardiac, renal,
cerebralcerebral

8. 88
………………Determinants of the management planDeterminants of the management plan
 Surgery:Surgery:
 Type: emergency or electiveType: emergency or elective
 Minor or major procedureMinor or major procedure
 Type of anesthesiaType of anesthesia
 Post operative oral intakePost operative oral intake

9. 99
Pre-operative managementPre-operative management
 Metabolic stress of surgery andMetabolic stress of surgery and
anesthesia cause increasedanesthesia cause increased
production of catecholamine,production of catecholamine,
glucocorticoids, glucagon, and growthglucocorticoids, glucagon, and growth
hormone all of which result inhormone all of which result in
hyperglycemia in the pre-operativehyperglycemia in the pre-operative
period.period.

10. 1010
Pre-operative managementPre-operative management
 The glycemic control is aimed toThe glycemic control is aimed to
achieve a fasting plasma glucose of <achieve a fasting plasma glucose of <
7.5 mmol/l and post prandial plasma7.5 mmol/l and post prandial plasma
glucose of < 10 mmol/l.glucose of < 10 mmol/l.
 Insulin dependent diabetic patients canInsulin dependent diabetic patients can
be admitted 2-3 days prior to surgery tobe admitted 2-3 days prior to surgery to
achieve satisfactory control.achieve satisfactory control.

11. 1111
Cont.Cont.
 In T2DM patients, if the control is goodIn T2DM patients, if the control is good
with OHAs, these drugs are continuedwith OHAs, these drugs are continued
and stopped on the day of the surgery.and stopped on the day of the surgery.
 If glycemic control is not good withIf glycemic control is not good with
OHAs, the drugs are stopped one weekOHAs, the drugs are stopped one week
before surgery and admitted for insulinbefore surgery and admitted for insulin
therapy.therapy.

12. 1212
Cont.Cont.
 If glycemic control is not good withIf glycemic control is not good with
insulin, the doses should be intensifiedinsulin, the doses should be intensified
with multiple dose regimen (split mixedwith multiple dose regimen (split mixed
of basal bolus).of basal bolus).

13. 1313
Subcutaneous insulin therapy afterSubcutaneous insulin therapy after
admissionadmission
 In elective surgery cases, start short
acting (3 time daily) and intermediate
acting (2 times daily) insulins are
started.
 When the fasting plasma glucose is
>7.5 mmol/l, increment by 2-4 units of
intermediate acting insulin at night is
needed.

14. 1414
…….Subcutaneous insulin therapy after admission.Subcutaneous insulin therapy after admission
 When the prediner plasma glucose isWhen the prediner plasma glucose is
>7.5 mmol/l, give 2-4 units of soluble>7.5 mmol/l, give 2-4 units of soluble
insulin subcutaneously before breakfastinsulin subcutaneously before breakfast
next day and then monitor beforenext day and then monitor before
prediner blood sugar.prediner blood sugar.

15. 1515
……..Subcutaneous insulin therapy after admission..Subcutaneous insulin therapy after admission
 When 2ABF plasma glucose is >10When 2ABF plasma glucose is >10
mmol/l, increment by 2-4 units of shortmmol/l, increment by 2-4 units of short
acting insulin in the morning is needed.acting insulin in the morning is needed.
 When 2AL plasma glucose is >10When 2AL plasma glucose is >10
mmol/l, increment by 2-4 units of shortmmol/l, increment by 2-4 units of short
acting insulin before lunch is needed.acting insulin before lunch is needed.
 When 2AD plasma glucose is >10 mmol/l,When 2AD plasma glucose is >10 mmol/l,
increment by 2-4 units of short actingincrement by 2-4 units of short acting
insulin before diner is needed.insulin before diner is needed.
All doses are for the next day.

16. 1616
…………Subcutaneous insulin therapy after admissionSubcutaneous insulin therapy after admission
 For every 2.2mmol/l rise in premeal
sugar , pre-meal one unit of soluble
insulin is added to the previous dose
of pre-meal insulin
 If the blood sugar level is more than
16.6 mmol/l, 15 units of soluble
insulin pre-meal three times a day is
tried.

17. 1717
On the day of surgeryOn the day of surgery
 It is preferable to take diabetic
patients for surgery in the morning
as first case.
 Normally the requirement of insulin
is 0.3 U to metabolize 1gm of
glucose.
 When FPG < 6 mmol/l, no insulin is
given except 5% glucose.

18. 1818
On the day of surgeryOn the day of surgery
 When FPG 6 -9 mmol/l, glucose
with 5 units soluble insulin should
be infused.
 For FPG 9-11mmol/l, 5 % glucose
with 8 U of soluble insulin is
infused.

19. 1919
Cont.Cont.
 If FPG is 11-14 mmol/l, 5 % glucose
with 10 U of soluble insulin should
be continued.
 Values between 14-16.6 mmol/l
needs normal saline with 6-8 U .

20. 2020
Cont.Cont.
 If the blood sugar > 16.6 mmol/l, 8-10If the blood sugar > 16.6 mmol/l, 8-10
U are added to normal saline andU are added to normal saline and
surgery is delayed for few hours tillsurgery is delayed for few hours till
satisfactory glycemic control issatisfactory glycemic control is
achieved.achieved.
 All the above infusions are given at theAll the above infusions are given at the
rate of 100-120 ml / h .rate of 100-120 ml / h .

21. GKI protocol (Glucose-Potassium-
Insulin):
Very important regimen:
500ml 10% glucose (50gm) + 10 mmol
pottasium + 15 U insulin.
@100ml/hour= 1600 drops/ 60 min= 26
d/min).
Insulin increment may be needed if blood
glucose > 10mmol/l.

22. 2222
Emergency surgeryEmergency surgery
 The Endocrinology team/consultant on callThe Endocrinology team/consultant on call
should be contacted about all patients withshould be contacted about all patients with
diabetes who require emergency surgerydiabetes who require emergency surgery
 In preparation for emergency surgery, the ptIn preparation for emergency surgery, the pt
should first be assessed clinically andshould first be assessed clinically and
biochemically (blood gas including glucosebiochemically (blood gas including glucose
and bedside ketones test, along with U&E,and bedside ketones test, along with U&E,
FBE and other pre-op bloods as required).FBE and other pre-op bloods as required).

23. 2323
Minor surgeryMinor surgery
 For minor surgery the antidiabetic drugs
and insulin are stopped on the day of
surgery. Once the surgery is over, the
patient is permitted to resume oral feeds
the antidiabetic drugs are started with
half the dose which the patient was
originally taking, on the second post
operative day full dose of the oral drugs
and or insulins should be started.

24. 2424
Practical aspectsPractical aspects
1.1. Whatever is the pattern of infusion, the bloodWhatever is the pattern of infusion, the blood
sugar has to be checked every tow hours andsugar has to be checked every tow hours and
the flow rate is adjusted.the flow rate is adjusted.
2.2. Intra and post operative potassium monitoringIntra and post operative potassium monitoring
should be done and corrected appropriately.should be done and corrected appropriately.
3.3. A few hours after surgery there will beA few hours after surgery there will be
reduction in the insulin requirement as thereduction in the insulin requirement as the
elevated counter hormones due to surgicalelevated counter hormones due to surgical
stress will decline.stress will decline.

25. 2525
Special situationsSpecial situations
1.1. Blood sugar may rapidly fall afterBlood sugar may rapidly fall after
surgical drainage of an infected area.surgical drainage of an infected area.
2.2. Type 2 diabetes can be safely switchedType 2 diabetes can be safely switched
over to oral drugs after a week or so.over to oral drugs after a week or so.
3.3. In coronary artery bypass surgery andIn coronary artery bypass surgery and
during and after renal transplantation,during and after renal transplantation,
the insulin requirements will bethe insulin requirements will be
exceptionally high and should beexceptionally high and should be
continued for at least 6 months.continued for at least 6 months.

26. 2626
Post operative managementPost operative management
 With the resumption of oral feedsWith the resumption of oral feeds
subcutaneous insulin can be started.subcutaneous insulin can be started.
 T2DM patients can resume their oralT2DM patients can resume their oral
antidiabetic drugs after week if there isantidiabetic drugs after week if there is
no complications of surgery.no complications of surgery.

27. 2727
Intravenous fluidsIntravenous fluids
 Dextrose saline / normal saline is usedDextrose saline / normal saline is used
if blood pressure is low or normal.if blood pressure is low or normal.
 If there is hypertension half normalIf there is hypertension half normal
saline or 5 % dextrose is given.saline or 5 % dextrose is given.

28. 2828
Intravenous fluidsIntravenous fluids
 For normal metabolism 50 gm glucose isFor normal metabolism 50 gm glucose is
required every 8 hours for energy and torequired every 8 hours for energy and to
avoid ketosis, to meet this demand atavoid ketosis, to meet this demand at
least 1000 cc 5 % glucose every 8 h willleast 1000 cc 5 % glucose every 8 h will
be required.be required.
 In situations requiring fluid restrictionIn situations requiring fluid restriction
10% dextrose can be infused instead of 510% dextrose can be infused instead of 5
% with double the dose of insulin.% with double the dose of insulin.

29. 2929
TargetsTargets
 To make patients safe for surgery, we needTo make patients safe for surgery, we need
an understanding and team work betweenan understanding and team work between
the surgeon, anesthetist and diabetologist.the surgeon, anesthetist and diabetologist.
 When the patient is under anesthesia theWhen the patient is under anesthesia the
ideal is to have diabetic therapy supervisedideal is to have diabetic therapy supervised
by a diabetic team where available.by a diabetic team where available.

30. Case 1Case 1
 60 year old, 60 kg man, height 16560 year old, 60 kg man, height 165
cm; scheduled for abdominoperinealcm; scheduled for abdominoperineal
resection of Ca. rectumresection of Ca. rectum
 Known diabetic on Metformin andKnown diabetic on Metformin and
Glibenclamide, BD doseGlibenclamide, BD dose
 Hypertension, CAD under checkHypertension, CAD under check
 BG: (F) = 7, (PP) = 9 mmol/l.BG: (F) = 7, (PP) = 9 mmol/l.
Switch over to insulin pre-op?Switch over to insulin pre-op?
Pre-op orders?Pre-op orders?

31. Case 1
 60 year old, 60 kg man, height 16560 year old, 60 kg man, height 165
cm; scheduled for abdominoperinealcm; scheduled for abdominoperineal
resection of Ca. rectumresection of Ca. rectum
 Known diabetic on Metformin andKnown diabetic on Metformin and
Glibenclimide, BD doseGlibenclimide, BD dose
 Hypertension, CAD under checkHypertension, CAD under check
 BG: (F) = 120, (PP) = 170 mg.dlBG: (F) = 120, (PP) = 170 mg.dl-1-1
 Morning BG=5; ½ h intra-op=8.5Morning BG=5; ½ h intra-op=8.5
mmol/l.mmol/l.
Intra-op fluids and insulin?Intra-op fluids and insulin?

32. Case 2Case 2
 40 year old, 45 kg lady
 Known diabetic on oral antihyperglycemics
 High grade fever x 1wk, vomiting x till 2
days back, altered sensorium x 12 h
 P=120 bpm, BP=70/40, BG=470 mg.dl-1
,
 Blood Ketones (+++), pH=6.8, Na+
-116, K+
-
3.4, HCO3-10, PCO2- 34, PO2- 78 mmHg
 Emergency laparotomy
 Yes/No? How quickly? What till
then?

33.  Yes!Yes!
 2-3 h may be enough2-3 h may be enough

34. 3434
Surgery with DKASurgery with DKA
 If ketoacidosis is present, treatment according toIf ketoacidosis is present, treatment according to
the the diabetic ketoacidosis protocoldiabetic ketoacidosis protocol should be should be
commenced immediately and the patient'scommenced immediately and the patient's
circulating volume and electrolytes stabilisedcirculating volume and electrolytes stabilised
before surgery. before surgery.
 Where DKA is present, initial insulin infusionWhere DKA is present, initial insulin infusion
rates will be 0.1U/kg/hr (or 0.04U/kg/hr). rates will be 0.1U/kg/hr (or 0.04U/kg/hr).
 This rate should be continued until ketones haveThis rate should be continued until ketones have
cleared and acidosis has corrected (see DKAcleared and acidosis has corrected (see DKA
protocol)protocol)

35. 3535
……. Surgery with DKA. Surgery with DKA
 Once ketones have cleared and acidosis hasOnce ketones have cleared and acidosis has
corrected, the insulin infusion rates may becorrected, the insulin infusion rates may be
reduced and the dextrose concentration of i.v.reduced and the dextrose concentration of i.v.
fluids adjusted as appropriate to maintain BGLsfluids adjusted as appropriate to maintain BGLs
between 6-10 mmol/l. Maintenance insulinbetween 6-10 mmol/l. Maintenance insulin
infusion rates once ketosis/acidosis has fullyinfusion rates once ketosis/acidosis has fully
cleared are usually in the range of 0.02-cleared are usually in the range of 0.02-
0.03U/kg/hr; the endocrinology team will advise0.03U/kg/hr; the endocrinology team will advise
on this. on this.

36. 3636
……. Surgery with DKA. Surgery with DKA
 The insulin infusion is made up by adding 50The insulin infusion is made up by adding 50
units (0.5 ml) of regular insulin (Actrapid 100 U)units (0.5 ml) of regular insulin (Actrapid 100 U)
to 49.5 ml 0.9% NaCl (1 unit/ml solution). Shortto 49.5 ml 0.9% NaCl (1 unit/ml solution). Short
acting insulins can also be used.acting insulins can also be used.
 The insulin infusion may run as a sideline withThe insulin infusion may run as a sideline with
the maintenance fluids via a three-way tap,the maintenance fluids via a three-way tap,
provided a syringe pump is used. Ensure that theprovided a syringe pump is used. Ensure that the
insulin is clearly labeled.insulin is clearly labeled.

37. 3737
……. Surgery with DKA. Surgery with DKA
 The initial rate of the insulin infusion shouldThe initial rate of the insulin infusion should
be be 0.02 - 0.03U/kg/hr0.02 - 0.03U/kg/hr (note that this (note that this
maintenance rate is much lower than themaintenance rate is much lower than the
rate required to treat DKA). Start withrate required to treat DKA). Start with
0.02U/kg/hr if BGL is <10.0 mmol/l;0.02U/kg/hr if BGL is <10.0 mmol/l;
0.03U/kg/hr if BGL >10.0 mmol/l.0.03U/kg/hr if BGL >10.0 mmol/l.

38. Confounding factors in aConfounding factors in a
diabetics for emergency surgerydiabetics for emergency surgery
 Usually associated with
 infective process
 pronounced hyperglycemia,
dehydration and hypovolumia
 metabolic decompensation
 ± DKA/ HHS

39. Thank You AllThank You All