PERI OPERATIVE MANAGEMENT

DR.N K AGRAWAL

DIABETES MELLITUS

MYTHS!

DEXTROSE SHOULD NOT BE GIVEN !

SHIFT THE PATIENT TO INSULIN !

PRE OPERATIVE NO DEXTROSE- NO INSULIN !

MANAGE PATIENT ON SLINDING SCALE !

FOUR HOURLY BLOOD GLUCOSE !

LOW SUGAR , HIGH PROTIEN DIET

FOLLOWING QUERIES WILL BE ANSWERED.

WHY TO CONTROL DM?

PRE OPERATIVE PHASE-TO SHIFT TO INSULIN?

WHETHER TO STOP OR CONTINUE OHG ?

FASTING PHASE MANAGEMENT

CHALLENGES FOR ANESTHETIST

EFFECT OF ANESTHETIC AGENTS ?

GLUCOSE MONITORING

POST OPERATIVE MANAGEMENT

WHY TO CONTROL DM ?

INTRA OPERATIVE PERIOD THE PATIENT MAY HAVE -

HYPERGLYCEMIA

OR

HYPOGLYCEMIA

HYPERGLYCEMIA

NON ENZYMATIC GLYCOSYLATION LEADS TO

DEPOSITION OF PROTIEN ON ENDOTHELIAL CELL - WEAKENS IT- HENCE NON HEALING

MACROGLUBULIN FORMED BY LIVER –INCREASES BLOOD VISCOSITY- CELL OEDEMA

HbA1c > 8.5%- DISTRUBS AUTOREGULATION

THE PATIENTS MAY LAND INTO

DKA

OR

HHGS

PATIENT MAY HAVE-

CEREBRAL OEDEMA

DELAYED RECOVERY

DIABETIC COMA

HIGHER BLOOD GLUCOSE LEVEL MAY CAUSE

DEALYED WOUND HEALING

POST OPERATIVE INFECTION

HYPERGLYCEMIA AND INFECTION

POST OP GLUCOSE RISK RATIO INFECTION

121-206 1%

202-350 1.17%

230-353 1.86%

250-360 1.90%

HYPOGLYCEMIA

BGL < 60 mg/dl

IT MAY LEAD TO DAMAGE OF VITAL ORGANS LIKE:

BRAIN CELLS LIVER CELLS R.B. CELLS SUPRA RENAL GLAND

WHICH ARE SOLELY DEPENDANT ON GLUCOSE FOR ENERGY

50% DEXTROSE IS USED TO BRING BGL >100 mg/dl

PRE OPERATIVE PHASE

WE NEED TO HAVE PROPER CONTROL OF GLUCOSE LEVEL

RANGE: 100mg/dl - 140 mg/dl

HbA1c < 7.5%

SHORT FASTING PERIOD

NO KETONES IN URINE

`

CO MORBID CONDITIONS LIKE

OBESITY

IHD

HT

RENAL

ANS

SHOULD BE EXPLAINED TO RELATIVES

PATIENT AND RELATIVES SHOULD BE MADE

AWARE OF SIGNS OF HYPOGLYCEMIA IN THE

POST-OPERATIVE PERIOD

ELECTIVE SURGERY MAY BE DELAYED

IF KETONES ARE POSITIVE - TREAT IT FIRST

WHETHER TO SHIFT ALL THE PATIENTS TO

INSULIN ?

RECENT RECOMMADATIONS

IF THE SURGERY IS PLANNED UNDER

LOCAL ANESTHESIA

NERVE BLOCK

NEURO AXIAL BLOCK

NO NEED TO SHIFT TO INSULIN

NOTE: DM PATIENTS ARE SENSITIVE TO LOCAL ANESTHETIC, HENCE LOWER DOSE IS NEEDED

THIS PATIENTS MAY BE VERY WELL TAKEN FOR SURGERY WITH ORAL HYPOGLYCEMIC DRUGS.

NOTE: DM PATIENTS ARE SENSITIVE TO LOCAL ANESTHETIC, HENCE LOWER DOSE IS NEEDED

DO ALL PATIENTS UNDER GA REQUIREDTO SHIFT TO INSULIN ?

NO

CRITERIA

PATIENTS IN WHOM ORAL FLUID CAN BE STARTED WITHIN FOUR HOURS OF GENERAL ANESTHESIA MAY BE CARRIED OUT WITH

ORAL HYPOGLYCEMIC DRUGS

SURGERIES LIKE-

CLOSE REDUCTIONS

LAP APPENDIX

LAP CHOLECYSTECTOMY

LAP TUBECTOMY etc. etc

WHICH PATIENTS ARE TO BE SHIFTED?

PATIENTS IN WHICH POST OPERATIVE PARALYTIC ILEUS IS EXPECTED

OR

PROLONGED VENTILATION

OR

ORAL FLUID IS PROHIBITED

ARE TO BE CONTROLLED ON INSULIN

IF PATIENTS ARE ON ORAL HYPOGLYCEMIC IT MAY REQUIRE

5 -7 DAYS TO SHIFT TO INSULIN

THIS IS BECAUSE OF HALF LIFE OF ORAL HYPOGLYCEMIC DRUGS 36-60 HOURS

INTRA OPERATIVE PHASE

THE STRESS OF SURGERY

THE ANESTHETICS USED

MAY AFFECT BLOOD GLUCOSE LEVEL

THE STRESS OF SURGERY

THIS RELEASES SOME CATABOLIC HORMONES,

INHIBITS SOME ANABOLIC HORMONES LIKE INSULIN

LEADS TO HYPERGLYCEMIA

ANESTHETIC AGENTS

BENZODIAZEPINES

REDUCES SECRETION OF ACTH

HENCE CORTISOL

DECREASES HYPERGLYCEMIC RESPONSE

OPIATES

THEY PROVIDE - HAEMODYNAMIC

- HORMONAL

- METABOLIC STABILITY

OPIATES BLOCKS ENTIRE SYMPATHETIC ACTIVITY AND ALSO INHIBITS HYPOTHALAMUS PITUTARY AXIS

OPIATES REDUCES HYPERGLYCEMIC RESPONES

INHALATIONAL AGENTS

HALOTHANE, ENFLURANE AND ISOFLURANE

REDUCES INSULIN RESPONSE TO GLUCOSE

LEADS TO HYPERGLYCEMIA

HAS NEGATIVE INOTROPIC EFFECT

INDUCING AGENTS

THEY ARE KNOWN TO REDUCE LIPID

CLEARANCE FROM CIRCULATION AND ALSO

DECREASE INSULIN RESPONSE

LEADS TO HYPERGLYCEMIA

MUSCLE RELAXANT

SUCCINYL CHOLIN SHOULD BE USED CAUTIOUSLY

THIS PATIENT MAY HAVE HIGHER POTASSIUM

“SLIDING INSULIN SCALE”

HAS NO ROLE IN

PERI AND POST OPERATIVE MANAGMENT

CHALLENGES

STIFF NECK SYNDROME

OBESITY

CORONARY ISCHEMIC DISEASE

NEPHROPATHY

RETINOPATHY

AUTONOMIC SYSTEM IMBALANCE

THE REASON OF THIS END ORGAN DAMAGE IS

THAT GLUCOSE COMPETES WITH OXYGEN TO

BE CARRIED TO TISSUE VIA HEMOGLOBIN

HENCE HYPOXIA OCCURS AT THIS LEVEL

FASTING PHASE

NON TIGHT CONTROL REGIME

NBM FOR 4-6 HOURS

BEFORE 2 HOURS OR DURING FASTING HYPOGLYCEMIA CAN BE MANAGED WITH CLEAR JUICE OR 5% DEXTROSE @ 2mg/kg/hr

DO THE MORNING BLOOD SUGAR

TRY TO KEEP BGL- 100 mg/dl - 140mg/dl

TIGHT CONTROL REGIME

FASTING FOR 4-6 HOURS

CLEAR WATER UPTO 2 HOURS

NO SUGAR

IF HYPOGLYCEMIA GLUCOSE 1mg/kg/hr

KEEP BGL 80-120 mg/dl

ALL PATIENTS UNDER INSULIN REGIME

REQUIRES BOTH DEXTROSE AND INSULIN

DEXTROSE IS REQUIRED BY CELLS FOR ENERGY

INSULIN REQUIRED FOR METABOLISM OF GLUCOSE AT CELL MEMBRANE LEVEL

PLEASE DO NOT AVOID INSULIN IF PATIENT IS MANAGED ON INSULIN,

INTRA OPERATIVELY

THIS MAY CAUSE KETOACIDOSIS

IV FLUID FOR PATIENTS ON ORAL

BLOOD SUGAR

IF < 100 mg/dl - DNS

IF > 100mg/dl - NS OR RL

IF PATIENT ON INSULIN

BLOOD SUGAR < 100 mg/dl - DNS

BLOOD SUGAR >100 mg/dl - DNS with insulin

MORNING DOSE- 20-40 % OF DAILY DOSE, SC SHORT ACTING INSULIN IF NO INSULIN PUMP IS PLANNED FOUR HOURS BEFORE

PREPERATION OF INSULIN DRIP—

50 UNITS IN 250 ml ( NS WITH KCL)

THAT IS 1 UNIT/ 5ML

1 UNIT OF INSULIN METABOLISES 2.5 gm GLUCOSE

2.5 gm GIVES 10 KCAL

MEANS 1 UNIT METABOLISE 10 KCAL

TOTAL CIRCULATING BLOOD SUGAR IS AROUND 100mg/dl IF CIRCULATING BLOOD IS 5 Lit. 100 X 50 =

5 GM OF GLUCOSE IN A NORMAL PATIENT IN CIRCULATION

1 UNIT OF INSULIN REDUCES BGL BY

30-40 mg/dl

SAME AS GLUCOSE

1 GM OF PROTINE GIVES 4 KCAL

INTRA OPERATIVE MANAGMENT

DO BLOOD SUGAR EVERY HOUR

INSULIN DOSE - BLOOD SUGAR/ 150

ON STEROIDS - BLOOD SUGAR/100

WAY TO REMEMBER INSULIN DOSE

1 – 2--3

2– 3– 4

3– 4—5

1 UNIT FOR 200-300 mg/dl

2 UNIT FOR 300 -400 mg/dl

3 UNIT FOR 400-500 mg/dl

NO REFERENCE FOR IT

THIS IS NOT TRUE FOR PAEDIATRIC AGE GROUP

THE DOSE SHOULD - 0.02 TO 0.05 U/kg

PLEASE REMEMBER TO MONITOR

URINE KETONE

INTRA OP BLOOD SUGAR TO BE KEPT BETWEEN

100- 200 mg/dl

SUGAR TO BE MONITORED HOURLY

TREAT HYPO OR HYPERGLYCEMIA AS NEEDED

PLEASE DO NOT DO BLOOD SUGAR WHEN A SUGAR CONTAINIG FLUID IS RUNNING

IT MAY SHOW HIGHER BGL BY 40-60 %

POST OPERATIVE

START ORAL AS SOON AS POSSIBLE

TWO HOURLY BLOOD SUGAR

PATIENTS ON ORAL HYPOGLYCEMIC- FLUID TO BE GIVEN AS EARLYAS POSSIBLE

IF ON INSULIN TO BE MANAGED ON INSULIN PUMP

NO OPIATES

REFERENCES

NHS- MANAGEMENT OF ADULT WITH DIABETES UNDERGOING SURGERY AND ELECTIVE PROCEDURE -2011

PERI OPERATIVE DIABETES MANAGEMENT GUIDELINES- AUSTRALIAN DIABETES SOCIETY -2012

MILLER”S ANESTHESIA TEXT BOOK

SUMMARY-1

PREOPERATIVE

OPTIMISATION - BGL-100-140 mg/dl

HbA1C < 7%

FASTING FOR 4-6 HOURS ONLY

GIVE HYPOGLYCEMIA COVER WITH

1-2 mg/kg/hr DEXTROSE

TAKE AS FIRST CASE

MAJOR SURGERY - NON INSULIN

NO ORAL HYPOGLYCEMIC IN MORNING

MONITOR SUGAR HOURLY

MAINTAIN BGL -100-180 mg/dl

ON INSULIN

30-40% OF DAILY REQUIRMENT SC OR

NO INSULIN IF INSULIN PUMP IS PLANNED INTRA OPERATIVE

BGL 180-200 mg/dl TO BE MAINTAINED

POST OPERATIVE

HOURLY BGL FOR FIRST 24 HOURS

MANAGE ON INSULIN

OR

GIVE ORAL HYPOGLYCEMIC WITH FIRST MEAL