diabetes mellitus

Perioperative Management Perioperative Management of of

Diabetes MellitusDiabetes Mellitus

Amir B. ChannaAmir B. Channa

FFARCS, D.A. (Eng)FFARCS, D.A. (Eng)

KKUH - RiyadhKKUH - Riyadh

The global incidence of diabetes is The global incidence of diabetes is rising and the number of people rising and the number of people affected is projected to exceed 300 affected is projected to exceed 300 million by the year 2025million by the year 2025Type 2 diabetes affects over 90% of Type 2 diabetes affects over 90% of diabetics diabetics 25% of world population obese – 25% of world population obese – dramatic rise in incidence of type 2 dramatic rise in incidence of type 2 diabetesdiabetes

IntroductionIntroduction

IntroductionIntroductionDiabetes Mellitus, the most commonly Diabetes Mellitus, the most commonly encountered perioperative encountered perioperative endocrinopathy, continuous to increase endocrinopathy, continuous to increase dramatically in prevalencedramatically in prevalence

Diabetic patients commonly have Diabetic patients commonly have microvascular and macrovascular microvascular and macrovascular pathology that influences their pathology that influences their perioperative course and critical illness perioperative course and critical illness and increases morbidity and mortality and increases morbidity and mortality rates during hospitalization.rates during hospitalization.

IntroductionIntroduction

Since diabetics require more Since diabetics require more surgeries than their nondiabetic surgeries than their nondiabetic counterparts, counterparts, – preemptive identification andpreemptive identification and– anticipation of diabetic complicationsanticipation of diabetic complications– and comorbidities, and comorbidities, – along with an optimized treatment plan, along with an optimized treatment plan,

are the foundation for the proper care of are the foundation for the proper care of this growing patient populationthis growing patient population

IntroductionIntroductionAggressive glycemic management Aggressive glycemic management improves short- and long-term outcomes improves short- and long-term outcomes in diabetic patients with acute myocardial in diabetic patients with acute myocardial infarction and cardiac surgical patients. infarction and cardiac surgical patients. Recently is has been shown that tight Recently is has been shown that tight glycemic control in both diabetic and glycemic control in both diabetic and nondiabetic hyperglycemic intensive care nondiabetic hyperglycemic intensive care patients resulted in improved survivalpatients resulted in improved survivalBlood glucose readings > 12.2 mmol/l on Blood glucose readings > 12.2 mmol/l on the first post-op day are associated with a the first post-op day are associated with a 2.7 fold increased risk of infection2.7 fold increased risk of infection

EpidemiologyEpidemiology

Estimated 245 million people globallyEstimated 245 million people globally

20%of adult population20%of adult population

5% of all deaths each year5% of all deaths each year

80% of people with diabetes live in 80% of people with diabetes live in low and middle income countrieslow and middle income countries

Patients with diabetes:Patients with diabetes:what pre-operative assessment is what pre-operative assessment is

important?important?

Document the followingDocument the following– Type of diabetesType of diabetes– LL ength of time ength of time

since diagnosissince diagnosis– Current managementCurrent management– Current glycemic Current glycemic

controlcontrolHgBA1cHgBA1cGlucometer dataGlucometer data

– Presence of Presence of complicationscomplications

NeuropathyNeuropathyNephropathyNephropathyRetinopathyRetinopathy

Autonomic neuropathy increase risk of post op gastroparesis and urinary tract infection

Diabetic Acute Complications(1) Diabetic ketoacidosis.(2) (Hyperglycemic) hyperosmolarity non-ketotic states.(3) Hypoglycemia.

Diabetic Chronic Complications(i) Macro-angiopathy (4) Cerebrovascular disease (5) Coronary heart disease: Asymptomatic ischemia (6) Peripheral vascular disease (ii) Micro-angiopathy (7) Retinopathy (8) Nephropathy (9) Neuropahthy Peripheral neuropathy Autonomic neuropathy (iii) (10) Diabetic foot infection

Long-term Complications of Long-term Complications of Diabetes MellitusDiabetes Mellitus

BlindnessBlindness• Retinal hemorrhagesRetinal hemorrhages

Renal DiseaseRenal Disease Peripheral NeuropathyPeripheral Neuropathy• Numbness in “stocking glove” distribution (hands Numbness in “stocking glove” distribution (hands

and feet)and feet) Heart Disease and StrokeHeart Disease and Stroke• Chronic state of Hyperglycemia leads to early Chronic state of Hyperglycemia leads to early

atherosclerosisatherosclerosis Complications in PregnancyComplications in Pregnancy


Diffuse AtheroscleroisDiffuse Atherosclerois• AMIAMI• CVACVA• PVDPVD

HypertensionHypertension

• Renal failureRenal failure• Diabetic Diabetic

retinopathy/blindnessretinopathy/blindness• GangreneGangrene

10% of all diabetics develop renal disease usually resulting in dialysis

Diabetics are up to 4 times more likely to have heart

disease and up to 6 times more likely to have a stroke than a

non-diabetic



Peripheral NeuropathyPeripheral Neuropathy

• Silent MISilent MI Vague, poorly-defined symptom Vague, poorly-defined symptom

complexcomplex– Weakness

– Dizziness

– Malaise

– Confusion

Suspect MI in any diabetic with MI Suspect MI in any diabetic with MI signs/symptoms with or without CPsigns/symptoms with or without CP

Why is pre-op glycemic control Why is pre-op glycemic control important?important?

Poor glycemic controlPoor glycemic control– Increases dehydration and electrolyte Increases dehydration and electrolyte

abnormalitiesabnormalities– Impairs collagen formation and Impairs collagen formation and

decreases surgical wound strengthdecreases surgical wound strength– Increases risk of complicationsIncreases risk of complications

Medications for diabetes Medications for diabetes management associated with risksmanagement associated with risks

DiagnosisDiagnosis

1.1. Symptoms of diabetes + random Symptoms of diabetes + random plasma glucose > 11.1 mmol/lplasma glucose > 11.1 mmol/l

2.2. Fasting plasma glucose >7.0 mmol/lFasting plasma glucose >7.0 mmol/l

3.3. 2 hour Plasma glucose >11.1 2 hour Plasma glucose >11.1 mmol/l during a standard 75g mmol/l during a standard 75g glucose tolerance testglucose tolerance test

Regulation of GlucoseRegulation of Glucose

Insulin Glucagon

Glucagon and Insulin are opposites (antagonists) of each other.

Endocrine Effects of InsulinEndocrine Effects of Insulin Effects on LiverEffects on Liver• AnabolicAnabolic

Promotes glycogensisPromotes glycogensis Increases synthesis of triglycerides, Increases synthesis of triglycerides,

cholesterol and VLDLcholesterol and VLDL Increases protein synthesisIncreases protein synthesis Promotes glycoysisPromotes glycoysis

• AnticatabolicAnticatabolic Inhibits gylogensisInhibits gylogensis Inhibits ketogensisInhibits ketogensis Inhibits gluconeogensisInhibits gluconeogensis

ssss

Endocrine Effects of InsulinEndocrine Effects of Insulin Effects on MuscleEffects on Muscle• Promotes protein synthesisPromotes protein synthesis

Increases amino acid transportIncreases amino acid transport Stimulates ribosomal protein synthesisStimulates ribosomal protein synthesis

• Promotes glycogen synthesisPromotes glycogen synthesis Increases glucose transportIncreases glucose transport Enhances activity of glycogen sythetaseEnhances activity of glycogen sythetase Inhibits activity of glycogen Inhibits activity of glycogen

phosphorylasephosphorylase

Endocrine Effects of InsulinEndocrine Effects of Insulin Effects on FatEffects on Fat• Promotes triglyceride storagePromotes triglyceride storage

Induces lipoprotein lipase, making Induces lipoprotein lipase, making fatty acids available for absorption fatty acids available for absorption into fat cellsinto fat cells

• Increases glucose transport into fat Increases glucose transport into fat cells, thus increases availability of cells, thus increases availability of --glycerol phosphate for triglyceride glycerol phosphate for triglyceride synthesissynthesis

• Inhibits intracellular lipolysis Inhibits intracellular lipolysis

Etiological ClassificationEtiological Classification

1.1. Type I diabetes: Pancreatic Type I diabetes: Pancreatic β-cell β-cell destruction, usually leading to destruction, usually leading to absolute insulin deficiencyabsolute insulin deficiency

A.A. Immune mediatedImmune mediated

B.B. IdiopathicIdiopathic


1.1. Type I diabetesType I diabetes

2.2. Type 2 diabetes: Defective insulin Type 2 diabetes: Defective insulin secretion and usually insulin secretion and usually insulin resistanceresistance


1.1. Type I diabetesType I diabetes2.2. Type 2 diabetesType 2 diabetes3.3. Other specific typesOther specific types

a. Genetic defects of a. Genetic defects of β-cell functionβ-cell functionb. Genetic defects of insulin actionb. Genetic defects of insulin actionc. Diseases of the exocrine pancreasc. Diseases of the exocrine pancreas

d.d.EndocrinopathiesEndocrinopathies((pheo.cushing,cortico pheo.cushing,cortico steroids,acromegaly)steroids,acromegaly)e. Drug (thiazides) or chemical inducede. Drug (thiazides) or chemical inducedf. Infectionsf. Infectionsg. Associated genetic defectsg. Associated genetic defectsh. Uncommon auto-immune causesh. Uncommon auto-immune causes


1.1. Type I diabetesType I diabetes

2.2. Type 2 diabetesType 2 diabetes

3.3. Other specific typesOther specific types

4. 4. Gestational diabetes: Onset in, or Gestational diabetes: Onset in, or first diagnosed in pregnancyfirst diagnosed in pregnancy

Acute effects of hyperglycaemiaAcute effects of hyperglycaemiaDehydration and electrolyte disturbances Dehydration and electrolyte disturbances (due to osmotic diuresis)(due to osmotic diuresis)

Acidaemia Acidaemia (accumulation of lactic + ketoacids)(accumulation of lactic + ketoacids)

Fatigue, weight loss and muscle wasting Fatigue, weight loss and muscle wasting (lipolysis and proteolysis in absolute insulin (lipolysis and proteolysis in absolute insulin deficiency)deficiency)

Poor wound healing and impaired wound Poor wound healing and impaired wound strengthstrengthDiabetic ketoacidotic coma Diabetic ketoacidotic coma (Type I diabetics (Type I diabetics due to absolute insulin deficiency)due to absolute insulin deficiency)

Hyperosmolar Non-ketotic coma Hyperosmolar Non-ketotic coma (Type II (Type II diabetics)diabetics)

Chronic effects of Chronic effects of HyperglycaemiaHyperglycaemia

MicrovascularMicrovascular– Proliferative retinopathyProliferative retinopathy– Diabetic nephropathy (close association Diabetic nephropathy (close association

with hypertension, which is found in 30-with hypertension, which is found in 30-60% of diabetics)60% of diabetics)

MicrovascularMicrovascular

MacrovascularMacrovascular– AtherosclerosisAtherosclerosis

Coronary heart disease (beware silent Coronary heart disease (beware silent ischaemia, cardiomyopathy)ischaemia, cardiomyopathy)

Cerebrovascular diseaseCerebrovascular disease

Peripheral vascular diseasePeripheral vascular disease


MacrovascularMacrovascular

NeuropathicNeuropathic– PeripheralPeripheral

Motor (Mononeuropathies, pressure palsies)Motor (Mononeuropathies, pressure palsies)

Sensory polyneuropathySensory polyneuropathy

MicrovascularMicrovascularMicrovascularMicrovascularMacrovascularMacrovascularNeuropathicNeuropathic– PeripheralPeripheral– Autonomic Autonomic

DiarrheaDiarrheaUrinary incontinenceUrinary incontinencePostural hypotensionPostural hypotensionCardiac denervationCardiac denervationImpaired ventilatory control – risk of resp arrest with Impaired ventilatory control – risk of resp arrest with anaesthesiaanaesthesiaGastroparesisGastroparesis


MacrovascularMacrovascular

NeuropathicNeuropathic

““Stiff joint syndrome” (airway)Stiff joint syndrome” (airway)

Increased incidence of infectionsIncreased incidence of infections

Autonomic NeuropathyAutonomic Neuropathy

Orthostatic hypotensionOrthostatic hypotension

Resting tachycardiaResting tachycardia

Gastroparesis(vomiting,diarrhea)Gastroparesis(vomiting,diarrhea)

ImpotenceImpotence

Cardiac dysrhythmiasCardiac dysrhythmias

Asymptomatic hypoglycemiaAsymptomatic hypoglycemia

Sudden death syndromeSudden death syndrome

Peri-op problemsPeri-op problemsStress response to surgery with catabolic Stress response to surgery with catabolic hormone secretionhormone secretionInterruption of food intake, pre- and Interruption of food intake, pre- and perhaps post- surgery (also PONV)perhaps post- surgery (also PONV)Altered consciousness, masking the Altered consciousness, masking the symptoms of hypoglycaemiasymptoms of hypoglycaemiaCirculatory disturbance that may alter the Circulatory disturbance that may alter the uptake of s.c. insulinuptake of s.c. insulinThe altered physiological state resulting The altered physiological state resulting from end organ pathologyfrom end organ pathology

Peri-operative goalPeri-operative goal

Minimize morbidityMinimize morbidity

Avoiding hyperglycaemia and its Avoiding hyperglycaemia and its associated lipolysis, ketogenesis, associated lipolysis, ketogenesis, protein catabolism and electrolyte protein catabolism and electrolyte disturbancesdisturbances

Avoiding hypoglycaemiaAvoiding hypoglycaemia

How?How?Provide adequate insulin to the Provide adequate insulin to the patient to counteract the catabolic patient to counteract the catabolic processes that develop in response processes that develop in response to surgeryto surgeryGlucose needs to be provided to Glucose needs to be provided to meet the increased metabolic needs, meet the increased metabolic needs, caused by surgical stress, as well as caused by surgical stress, as well as basal metabolic requirementsbasal metabolic requirementsA simple regimen that is immune to A simple regimen that is immune to errorerror

Regimen depends onRegimen depends on

Type of diabetes and its usual Type of diabetes and its usual treatmenttreatment

Extent of surgeryExtent of surgery– The amount of surgical stress and the The amount of surgical stress and the

catabolic response to that stresscatabolic response to that stress– Beware major surgery and emergency Beware major surgery and emergency

surgery, especially trauma or surgery surgery, especially trauma or surgery related to infective processesrelated to infective processes

Type II diabetes on diet aloneType II diabetes on diet alone

If fasting blood glucose < 7.8 mmol/lIf fasting blood glucose < 7.8 mmol/l

Close observation including hourly Close observation including hourly dextrose measurement (glucometer dextrose measurement (glucometer in theatre)in theatre)

Conversion to a GIK regime if the Conversion to a GIK regime if the glucose rises >8.0 mmol/lglucose rises >8.0 mmol/l

Type II diabetes on oral Type II diabetes on oral hypoglycaemicshypoglycaemics

There are 4 groups of oral There are 4 groups of oral hypoglycaemic agents (OHA)hypoglycaemic agents (OHA)– Sulphonylureas Sulphonylureas

Enhanced secretion of insulin in response to Enhanced secretion of insulin in response to glucose and increased sensitivity at its glucose and increased sensitivity at its peripheral actionsperipheral actions

SulphonylureasSulphonylureas

Biguanides Biguanides – Promote glucose utilization and reduce Promote glucose utilization and reduce

hepatic glucose productionhepatic glucose production

SulphonylureasSulphonylureas

BiguanidesBiguanides

Thiazolidinediones (Rosiglitazone)Thiazolidinediones (Rosiglitazone)– Enhance insulin action in the peripheryEnhance insulin action in the periphery– Inhibit hepatic gluconeogenesisInhibit hepatic gluconeogenesis– Enhances glucose uptake into tissues Enhances glucose uptake into tissues

via GLUT-4 glucose transportervia GLUT-4 glucose transporter– Preserves the Preserves the ββ-cells of the pancreas-cells of the pancreas

SulphonylureasSulphonylureasBiguanidesBiguanidesThiazolidinedionesThiazolidinedionesModifiers of glucose absorption e.g.. Modifiers of glucose absorption e.g.. Ά-glucosidase inhibitor acarboseΆ-glucosidase inhibitor acarbose– Suppress the breakdown of complex Suppress the breakdown of complex

carbohydrates in the gut delaying the carbohydrates in the gut delaying the rise of blood sugar postprandiallyrise of blood sugar postprandially

? Stop the OHA before surgery? Stop the OHA before surgeryThe long acting sulphonylureas The long acting sulphonylureas should be stopped 3 days before should be stopped 3 days before surgery and converted to shorter surgery and converted to shorter acting drugs, or insulin if coming for acting drugs, or insulin if coming for major surgerymajor surgeryMetformin need not be stopped Metformin need not be stopped (recommendation used to be 2 days)(recommendation used to be 2 days)– Risk of lactic acidosis extremely lowRisk of lactic acidosis extremely low

Omit morning OHA doseOmit morning OHA dose

If the patient is for minor surgery the If the patient is for minor surgery the OHA is omitted on the day of surgery OHA is omitted on the day of surgery and they can then be treated without and they can then be treated without insulin, with close observation and insulin, with close observation and conversion to GIK if the glucose rises conversion to GIK if the glucose rises above 8.0 mmol/labove 8.0 mmol/l

If the patient is for major surgery the If the patient is for major surgery the patient should be established on insulin patient should be established on insulin pre-op, even if well controlled. There is pre-op, even if well controlled. There is good evidence that continuous I.v insulin good evidence that continuous I.v insulin infusions are superior to intermittent infusions are superior to intermittent s.c.boluses and also to I.v. bolusess.c.boluses and also to I.v. boluses

GIK systems GIK systems (Alberti regimen) (Alberti regimen) are are relatively safe as they provide insulin and relatively safe as they provide insulin and dextrose together, preventing potential dextrose together, preventing potential disasters.disasters.

Type I diabetesType I diabetes

These patients should all be treated These patients should all be treated on I.v. insulin infusion before, during on I.v. insulin infusion before, during and after surgery.and after surgery.

This is true for major surgery, This is true for major surgery, although there are some alternatives although there are some alternatives in minor surgeryin minor surgery

Preoperative InsulinPreoperative Insulin Traditional ApproachTraditional Approach

Give 1/4 to 1/2 the daily dose of Give 1/4 to 1/2 the daily dose of intermediate-acting insulin intermediate-acting insulin subcutaneouslysubcutaneously

Add 1/2 unit of intermediate-acting Add 1/2 unit of intermediate-acting insulin for each unit of insulin insulin for each unit of insulin prescribedprescribed

Start IV glucose 5-10 g/hStart IV glucose 5-10 g/h

Preoperative Insulin Preoperative Insulin Continuous IV InfusionContinuous IV Infusion

Place 50 U. Regular Insulin in 1000 ml NSPlace 50 U. Regular Insulin in 1000 ml NSGive 10 ml/hGive 10 ml/hMeasure blood glucose q.h.Measure blood glucose q.h.Adjust infusion rate to keep glucose level atAdjust infusion rate to keep glucose level at

120-180 mg/dl120-180 mg/dlTurn infusion off for 30 min if glucose level Turn infusion off for 30 min if glucose level falls below 80 mg/dlfalls below 80 mg/dlProvide sufficient glucose (5-10g/h) and Provide sufficient glucose (5-10g/h) and potassium (2-4 mEq/h)potassium (2-4 mEq/h)

New insulin delivery modesNew insulin delivery modes

Continuous subcutaneous infusionsContinuous subcutaneous infusions

Continuous intra-peritoneal infusionsContinuous intra-peritoneal infusions

Minor surgeryMinor surgeryIf patient is expected to resume oral intake If patient is expected to resume oral intake quickly after surgery, a reduced approach may quickly after surgery, a reduced approach may be acceptablebe acceptable

These patients will be given ½ their These patients will be given ½ their intermediate acting insulin, and a 5% dextrose intermediate acting insulin, and a 5% dextrose solution at 100-150 ml/hour to prevent solution at 100-150 ml/hour to prevent hypoglycaemia. hypoglycaemia.

Intra-op and recovery room blood sugar Intra-op and recovery room blood sugar monitoring is essential.monitoring is essential.

It is suggested that the blood sugar is It is suggested that the blood sugar is measured every 30 mins to hourly.measured every 30 mins to hourly.

Minor surgeryMinor surgeryKeep glucose between 4.4 – 8.0 Keep glucose between 4.4 – 8.0 mmol/lmmol/lBoth I.v insulin infusions and I.v Both I.v insulin infusions and I.v glucose may be needed to achieve glucose may be needed to achieve control.control.Once the patient has had their first Once the patient has had their first meal post-op they can be given the meal post-op they can be given the rest of their insulin dose depending rest of their insulin dose depending on the measured blood glucoseon the measured blood glucose

Major surgeryMajor surgeryPlaces a much larger catabolic stress on Places a much larger catabolic stress on patientspatientsA glucose, Potassium and insulin (GIK) A glucose, Potassium and insulin (GIK) infusion is a simple reliable way of controlling infusion is a simple reliable way of controlling the patient’s blood sugar in the perioperative the patient’s blood sugar in the perioperative periodperiodIdeally it should be started in the Ideally it should be started in the preoperative period especially in those preoperative period especially in those patients that are not well controlledpatients that are not well controlledIt is essential that there are frequent, It is essential that there are frequent, accurate measurements of the blood sugar accurate measurements of the blood sugar made throughout the perioperative period made throughout the perioperative period

Factors that need to be Factors that need to be consideredconsidered

GlucoseGlucose

InsulinInsulin

PotassiumPotassium

FluidsFluids

GlucoseGlucose

Sufficient glucose is given to prevent Sufficient glucose is given to prevent hypoglycaemia and to provide basal hypoglycaemia and to provide basal energy requirementsenergy requirements

It is recommended that 5-10g of It is recommended that 5-10g of dextrose is given per hour. dextrose is given per hour.

This can be given as 5% or 10% This can be given as 5% or 10% dextrose.dextrose.

An easy way is to give 0.1g/kg/hour An easy way is to give 0.1g/kg/hour

Example:Example:– 70kg x 0.1g/kg/hr = 7g/hr70kg x 0.1g/kg/hr = 7g/hr– 10% dextrose contains 100mg 10% dextrose contains 100mg

dextrose/ml or 1g dextrose/10mldextrose/ml or 1g dextrose/10ml– Give 70mls/hr of 10% dextroseGive 70mls/hr of 10% dextrose

For long-term infusions 0.9% sodium For long-term infusions 0.9% sodium chloride may be needed to prevent chloride may be needed to prevent hyponatraemiahyponatraemia

In diabetic paediatric patients, a In diabetic paediatric patients, a higher dose of dextrose is probably higher dose of dextrose is probably needed and it has been estimated needed and it has been estimated that 0.3g/kg/hr is sufficient to that 0.3g/kg/hr is sufficient to prevent hypoglycaemiaprevent hypoglycaemia

InsulinInsulinThe The β-cells in the pancreas secrete insulin in β-cells in the pancreas secrete insulin in response to glucose concentrations.response to glucose concentrations.Even the most sophisticated artificial insulin Even the most sophisticated artificial insulin delivery systems cannot replicate this delivery systems cannot replicate this responseresponseS.c. insulin will result in peaks and troughs S.c. insulin will result in peaks and troughs that risk the development of lipolysis and that risk the development of lipolysis and proteolysisproteolysisDuring surgery alterations in blood flow to the During surgery alterations in blood flow to the skin and subcutaneous tissue makes the skin and subcutaneous tissue makes the absorption of insulin even more unpredictableabsorption of insulin even more unpredictable

InsulinInsulinSoluble rapid onset insulins are used in Soluble rapid onset insulins are used in perioperative infusionsperioperative infusions

They have a short I.v. half life of about 5 They have a short I.v. half life of about 5 min, and a biological duration of action of min, and a biological duration of action of less than 20 min. less than 20 min.

This may result ins ‘roller coaster’ effect This may result ins ‘roller coaster’ effect on glucose concentrationson glucose concentrations

Continuous I.v. insulin infusion is the most Continuous I.v. insulin infusion is the most rational way to safely control blood sugarrational way to safely control blood sugar

The usual requirements are 0.25-0.35 The usual requirements are 0.25-0.35 Units insulin per gram of glucose per Units insulin per gram of glucose per hour.hour.Insulin requirements are increased Insulin requirements are increased with:with:– Liver diseaseLiver disease– ObesityObesity– Severe infectionsSevere infections– Steroid therapySteroid therapy– CPB CPB

PotassiumPotassiumSeveral factors affect the serum potassium Several factors affect the serum potassium level:level:– Insulin stimulates the uptake of potassium into Insulin stimulates the uptake of potassium into

cellscells– Dehydration can move K+ out of the cells and Dehydration can move K+ out of the cells and

into the bloodinto the blood– Hyperglycaemia can also move K+ out of the Hyperglycaemia can also move K+ out of the

cellscells– Acid-base changes (acidosis results in Acid-base changes (acidosis results in

hyperkalaemiahyperkalaemia

It has been suggested that each liter It has been suggested that each liter of dextrose containing fluid that is of dextrose containing fluid that is used in the GIK infusion contains used in the GIK infusion contains 40mEq KCL.40mEq KCL.This can be adjusted according to This can be adjusted according to plasma concentrationsplasma concentrationsAll diabetics should have potassium All diabetics should have potassium measured in the operating room in measured in the operating room in addition to glucoseaddition to glucose

FluidsFluidsAs long as the patient is receiving enough As long as the patient is receiving enough glucose, insulin and potassium any other glucose, insulin and potassium any other fluids needed intraoperatively should be fluids needed intraoperatively should be non-glucose containingnon-glucose containing

It has been suggested that lactated Ringers It has been suggested that lactated Ringers should not be used, as lactate is a should not be used, as lactate is a gluconeogenic precursor that is rapidly gluconeogenic precursor that is rapidly metabolized especially in a starved or metabolized especially in a starved or catabolic state. This may result in higher catabolic state. This may result in higher blood glucose concentrations, and should be blood glucose concentrations, and should be avoidedavoided

Suggested GIK regimenSuggested GIK regimenNormal insulin the day before surgeryNormal insulin the day before surgery– Do a blood sugar on the day of surgery, and Do a blood sugar on the day of surgery, and

once result known start infusiononce result known start infusion– 1. 1 liter 10% dextrose + 40 mEq/l KCL at 0.1g 1. 1 liter 10% dextrose + 40 mEq/l KCL at 0.1g

dextrose/kg/hrdextrose/kg/hr– 2. Insulin infusion of 50 U rapid acting insulin in 2. Insulin infusion of 50 U rapid acting insulin in

250 ml 0.9% NaCl piggybacked to the dextrose 250 ml 0.9% NaCl piggybacked to the dextrose and run at 1-2 U/hr depending on hourly (or and run at 1-2 U/hr depending on hourly (or more) measurements of glucosemore) measurements of glucose

– Care should be taken that neither infusion is Care should be taken that neither infusion is allowed to stop while the other continues allowed to stop while the other continues runningrunning

Insulin infusionInsulin infusion

Blood sugarBlood sugar InsulinInsulin

5-10 mmol/l5-10 mmol/l 2 U/hr 2 U/hr (10ml/hr)(10ml/hr)

10-13 mmol/l10-13 mmol/l 4 U/hr4 U/hr



>19 mmol/l>19 mmol/l 10 U/hr10 U/hr

The infusion should be continued The infusion should be continued post-op with hourly blood sugar post-op with hourly blood sugar monitoringmonitoring

The patient must eat as soon as The patient must eat as soon as possible, and must then be put on possible, and must then be put on the pre-op regimen that he was the pre-op regimen that he was controlled oncontrolled on

A few anaesthetic A few anaesthetic considerationsconsiderations

First case in the morning to minimize the First case in the morning to minimize the starvation periodstarvation period

No anaesthetic technique is indicated or No anaesthetic technique is indicated or contraindicated in diabetics, and the stress contraindicated in diabetics, and the stress imposed by the anaesthetic is usually imposed by the anaesthetic is usually minor compared to the stress of the minor compared to the stress of the surgery.surgery.

The challenge is to give the most stable The challenge is to give the most stable anaesthetic possible and limit the anaesthetic possible and limit the hyperglycaemic reaction to surgical stresshyperglycaemic reaction to surgical stress

Regional anaesthesiaRegional anaesthesiaPro:Pro:– Regional anaesthesia blunts the increases in Regional anaesthesia blunts the increases in

coritcol, glucagon, and glucose.coritcol, glucagon, and glucose.– Spinal or epidural may modulate the Spinal or epidural may modulate the

catecolamine secretion, preventing high catecolamine secretion, preventing high glucose and ketosis. This effect could continue glucose and ketosis. This effect could continue in the post operative period, if the block is in the post operative period, if the block is continuedcontinued

– An awake patient is a good monitor to prevent An awake patient is a good monitor to prevent hypoglycaemiahypoglycaemia

– A swifter return to normal eatingA swifter return to normal eating

Regional anaesthesiaRegional anaesthesiaCon:Con:– If If autonomic neuropathy autonomic neuropathy is present, profound is present, profound

hypotension may occur. This could be hypotension may occur. This could be disastrous in a patient with cardiac disastrous in a patient with cardiac complicationscomplications

– Infections and vascular complications Infections and vascular complications may be may be increased increased (epidural abscesses are more (epidural abscesses are more common in diabetics)common in diabetics)

– A diabetic neuropathy A diabetic neuropathy presenting post-op may presenting post-op may be attributed to the regional blockadebe attributed to the regional blockade

General AnaesthesiaGeneral Anaesthesia

Pro:Pro:– High dose opiate technique may be High dose opiate technique may be

useful to block the entire sympathetic useful to block the entire sympathetic nervous system and the hypothalamic nervous system and the hypothalamic pituitary axispituitary axis

– Better control of blood pressure in Better control of blood pressure in patients with autonomic neuropathypatients with autonomic neuropathy

General AnaesthesiaGeneral AnaesthesiaConCon– May have difficult airway (“Stiff-joint May have difficult airway (“Stiff-joint

syndrome”)syndrome”)– Full stomach due to gastroparesisFull stomach due to gastroparesis– Controlled ventilation is needed as patients Controlled ventilation is needed as patients

with autonomic neuropathy may have impaired with autonomic neuropathy may have impaired ventilatory controlventilatory control

– Aggravated haemodynamic response to Aggravated haemodynamic response to intubationintubation

– Anaesthesia masks the symptoms of Anaesthesia masks the symptoms of hypoglycaemiahypoglycaemia

SummarySummaryThe most important factors are good control The most important factors are good control of the patient’s perioperative blood glucose of the patient’s perioperative blood glucose concentrations to prevent the acute concentrations to prevent the acute complications of hyperglycaemiacomplications of hyperglycaemiaThe strict avoidance of any hypoglycaemiaThe strict avoidance of any hypoglycaemiaThe complications of diabetes should be The complications of diabetes should be sought out and the affected organs protected, sought out and the affected organs protected, especially the heart, brain and kidneysespecially the heart, brain and kidneysAn aggressive approach to glycaemic control An aggressive approach to glycaemic control will result in better wound healing, lower will result in better wound healing, lower mortality and shorter hospital staysmortality and shorter hospital stays

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Diabetes ComplicationsDiabetes Complications

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Diabetic KetoacidosisDiabetic Ketoacidosis

Most serious complication in Type 1 Most serious complication in Type 1 diabetesdiabetes

DKADKA

Questions??????

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Precipitating CausesPrecipitating Causes

Not enough insulinNot enough insulin

Skipping insulinSkipping insulin

Stress, traumaStress, trauma

Insulin resistanceInsulin resistance

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Pathophysiology of DKAPathophysiology of DKA

See chartSee chart

KetosisKetosis

DehydrationDehydration

Electrolyte imbalanceElectrolyte imbalance

Complications of DKA Complications of DKA and clues to their developmentand clues to their development

Acute gastric dilatation or erosive gastritisAcute gastric dilatation or erosive gastritis– by vomiting blood or coffee-ground materialby vomiting blood or coffee-ground material

Cerebral edemaCerebral edema– obtundation or coma with or without neuro. obtundation or coma with or without neuro.

Signs,Signs, especially if occurring with initial especially if occurring with initial improvement.improvement.

HyperkalemiaHyperkalemia cardiac arrestcardiac arrest

hypokalemia cardiac arrythmias.hypokalemia cardiac arrythmias.

Infection is known by feverInfection is known by fever

hypoglycemia is considered when there is hypoglycemia is considered when there is adrenergic or neuorologic signs or rebound ketosis.adrenergic or neuorologic signs or rebound ketosis.

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Symptoms of DKASymptoms of DKA

Abdominal painAbdominal pain

AnorexiaAnorexia


Fuity breathFuity breath

Kussmaul’s Kussmaul’s

Change LOCChange LOC

HypotensionHypotension

N&VN&V

PolyuriaPolyuria

SomnolenceSomnolence

TachycardiaTachycardia

ThirstThirst

Visual Visual disturbancesdisturbances

Warm, dry skinWarm, dry skin

WeaknessWeakness

Wt. lossWt. loss

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Assessment DKAAssessment DKA

HyperglycemiaHyperglycemia

HyperosmolalityHyperosmolality


Electrolyte imbalancesElectrolyte imbalances

Metabolic acidosisMetabolic acidosis

HypoglycemiaHypoglycemia

Fluid overloadFluid overload

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InterventionIntervention

RehydrateRehydrate

Reverse shockReverse shock

Give PotassiumGive Potassium

Corret pHCorret pH

Give insulinGive insulin

7979

Critical MonitoringCritical Monitoring

RehydrationRehydration– I & O, Daily WeightI & O, Daily Weight– Skin turgor, LOC, VSSkin turgor, LOC, VS– CVP measurementCVP measurement– Auscultation of lungsAuscultation of lungs

8080

IV Fluids in DKAIV Fluids in DKAHour 1Hour 1– N/S (15-20ml/kg)N/S (15-20ml/kg)

Hour 2Hour 2– Continue fluid, consider half-strength NSContinue fluid, consider half-strength NS

Hour 3Hour 3– Reduce fluid intake to 7.5ml/kg, use half-Reduce fluid intake to 7.5ml/kg, use half-

strength NSstrength NS

Hour 4Hour 4– Consider urine output in adjusting fluidsConsider urine output in adjusting fluids

8181

Potassium Replacement in DKAPotassium Replacement in DKA

Look at EKGLook at EKG

Replacement is based on plasma Replacement is based on plasma potassium levelpotassium level

Recheck potassium q 2 hoursRecheck potassium q 2 hours

8282

Correct pH/Give InsulinCorrect pH/Give Insulin

Give IV InsulinGive IV Insulin

Give Regular Insulin only Give Regular Insulin only – Initial bolus IV (0.15u/kg)Initial bolus IV (0.15u/kg)– Then Regular Insulin IV dripThen Regular Insulin IV drip

8383

HHNKHHNKHyperglycemic, Hyperosmolar Noketotic SyndromeHyperglycemic, Hyperosmolar Noketotic Syndrome

Most commonly occurs in older Most commonly occurs in older adults with Type II diabetesadults with Type II diabetes

Always look for precipitating factorsAlways look for precipitating factors

8484

Factors Associated with HHNKFactors Associated with HHNK

DrugsDrugs

ProceduresProcedures

Chronic illnessChronic illness

Acute illnessAcute illness

8585

Four Major Clinical FeaturesFour Major Clinical Features

Severe hyperglycemiaSevere hyperglycemia

No or slight ketosisNo or slight ketosis

Profound dehydrationProfound dehydration

HyperosmolalityHyperosmolality

8686

TreatmentTreatment

Similar to DKASimilar to DKA

Find underlying causeFind underlying cause

8787

HypoglycemiaHypoglycemia

Also known as Also known as insulin reactioninsulin reaction or or hypoglycemic reactionhypoglycemic reaction

8888

Risk FactorsRisk Factors

Overdose of insulinOverdose of insulin

Omitting a mealOmitting a meal

OverexertionOverexertion

Nausea and vomitingNausea and vomiting

Alcohol intakeAlcohol intake

8989

Symptoms of HypoglycemiaSymptoms of Hypoglycemia

AdrenergicAdrenergic– ShakinessShakiness– IrritabilityIrritability– NervousnessNervousness– TachycardiaTachycardia– TremorTremor– HungerHunger– DiaphoresisDiaphoresis– PallorPallor– ParesthesiasParesthesias

NeuroglycopenicNeuroglycopenic– HeadacheHeadache– Mental illnessMental illness– Inability to concentrateInability to concentrate– Slurred speechSlurred speech– Blurred visionBlurred vision– ConfusionConfusion– Irrational behaviorIrrational behavior– LethargyLethargy– LOC, coma, seizureLOC, coma, seizure

9090

InterventionsInterventions

MildMild– carbohydrate 10-15 gramcarbohydrate 10-15 gram

ModerateModerate– 20-30 gram of carbs20-30 gram of carbs– Glucagon, 1 mg SC or IMGlucagon, 1 mg SC or IM

SevereSevere– 50% dextrose 25 g IV50% dextrose 25 g IV– Glucagon 1 mg IM or IVGlucagon 1 mg IM or IV

Diabetes in PregnancyDiabetes in Pregnancy Early pregnancy (<24 weeks)Early pregnancy (<24 weeks)• Rapid embryo growthRapid embryo growth

• Decrease in maternal blood glucoseDecrease in maternal blood glucose

• Episodes of hypoglycemiaEpisodes of hypoglycemia

Diabetes in PregnancyDiabetes in Pregnancy Late pregnancy (>24 weeks)Late pregnancy (>24 weeks)• Increased resistance to insulin effectsIncreased resistance to insulin effects

• Increased blood glucoseIncreased blood glucose

• KetoacidosisKetoacidosis

Diabetes in PregnancyDiabetes in Pregnancy Increased maternal risk for:Increased maternal risk for:• Pregnancy-induced hypertensionPregnancy-induced hypertension

• Infections Infections VaginalVaginal Urinary tractUrinary tract

Diabetes in PregnancyDiabetes in Pregnancy Increased fetal risk for:Increased fetal risk for:• High birth weightHigh birth weight

• HypoglycemiaHypoglycemia

• Liver dysfunction-hyperbilirubinemiaLiver dysfunction-hyperbilirubinemia

• Hypocalcemia Hypocalcemia

9595

Acute Complications of Acute Complications of DiabetesDiabetes

CompareCompare– DKADKA– HHNKHHNK– HypoglycemiaHypoglycemia

– see chart for comparisonsee chart for comparison

9696

Other ComplicationsOther Complications

Hypoglycemic UnawarenessHypoglycemic Unawareness

Somogyi PhenomenonSomogyi Phenomenon

Dawn PhenomenonDawn Phenomenon

9797

Chronic ComplicationsChronic Complications

Macrovascular ComplicationsMacrovascular Complications

Microvascular ComplicationsMicrovascular Complications

Neuropathic ComplicationsNeuropathic Complications

MixedMixed

9898

Foot Infections with DiabetesFoot Infections with Diabetes

InspectionInspection

FootwearFootwear

Foot CareFoot Care

9999

Microvascular ComplicationsMicrovascular Complications

RetinopathyRetinopathy

NephropathyNephropathy

100100

Visual Complications of Visual Complications of DiabetesDiabetes

Education of client Education of client – Diabetic retinopathy can lead to Diabetic retinopathy can lead to

blindnessblindnessCheck blood sugarCheck blood sugar

Check blood pressureCheck blood pressure

Regular eye exam with ophthalmologistRegular eye exam with ophthalmologist

Laser photocoagulation therapyLaser photocoagulation therapy

THANK YOU !THANK YOU !

Long-term control of blood glucose Long-term control of blood glucose reduces the rate and severity of reduces the rate and severity of complicationscomplicationsBut even short-term glycemic control But even short-term glycemic control in hospitalized patients can in hospitalized patients can significantly lower morbidity and significantly lower morbidity and mortality in many areas, from mortality in many areas, from nosocomial infection to postoperative nosocomial infection to postoperative coursecourse

The results of traditional approaches to The results of traditional approaches to controlling blood glucose in hospitalized controlling blood glucose in hospitalized patients have been disappointing owing to patients have been disappointing owing to a variety of factors: a variety of factors: – use of oral agents that are difficult or use of oral agents that are difficult or

dangerous to use in inpatientsdangerous to use in inpatients– older insulin preparations with unphysiological older insulin preparations with unphysiological

modes of actionmodes of action– and even provider reluctance to accept and even provider reluctance to accept

glycemic control as an essential element of the glycemic control as an essential element of the care of the diabetic hospitalized patientcare of the diabetic hospitalized patient

The end point of each of the different The end point of each of the different etiologies is hyperglycaemiaetiologies is hyperglycaemia

The adverse effects of The adverse effects of hyperglycaemia are both acute and hyperglycaemia are both acute and chronicchronic

These need to be treated These need to be treated aggressively as the mortality of aggressively as the mortality of ketoacidosis is still estimated as up ketoacidosis is still estimated as up to 15%to 15%Hyperosmolar non-ketotic Hyperosmolar non-ketotic hyperglycaemic coma may carry an hyperglycaemic coma may carry an even higher mortality. even higher mortality. This is probably because this is an This is probably because this is an older group with a higher incidence older group with a higher incidence of co-existing diseaseof co-existing disease

diabetes mellitus

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