Periop management of diabetic patients

1. Perioperative Management
of Diabetic Patient
Dr.Surender pasupuleti
Professor
Dept. of Anaesthesiology
M.N.R. Medical College

2. Effect of Surgery on Diabetic
Patient
Perioperative stress
Secretion of Epinephrine, Norepinephrine,
Cortisol and Growth hormone
Glycogenolysis,Gluconeogenesis .
Protein catabolism
Hyperglycemia, Acidosis and
.Ketosis

3. • Hyperglycemia
• Hypoglycemia
Effect of Surgery on Diabetic
Patient

4. Adverse effects of Hyperglycemia
• Impair wound healing
• Decreased tensile strength of surgical wounds
• Increase in plasminogen activator factor inhibitor
• Abnormal platelet function
• Exacerbation of ischemic brain damage

5. EFFECT OF ANAESTHESIA ON
DIABETES
• ANAESTHETIC AGENT
• ANAESTHETIC TECHNIQUE

6. EFFECT OF ANAESTHESIA ON
DIABETES
• Marked increase ——-
Chloroform, Diethyl Ether, Cyclopropane,
Ketamine
• Slight increase ——
Halothane, isoflurane, sevoflurane
• Little or no effect ——
N2O, I.V. Induction agents, Analgesic
drugs , . Neuromuscular blocking
agents
ANAESTHETIC TECHNIQUE

7. Perioperative Management of
Diabetic Patient
• Preoperative Evaluation and
Stabilization
• Intraoperative Control and Monitoring
• Postoperative management.

8. Preoperative Evaluation
• Elective or Emergency
• Major or Minor, Vascular or Day care Surgery
• Status of diabetes
• Coexisting Medical problems and associated
surgical risks

9. Preoperative Evaluation
Metabolic
Status
End organ
changes
• Type and Duration
of Diabetes
• H/O Hypoglycemic or
ketotic attacks in
past
• Current therapy
diet, oral hypoglycemic
drug or insulin
• Determine
Physiological age of
patient

10. Type 1 :
Poor control:
1.75yrs for every chronological year of disease
Tight control:
1.25yrs for every chronological year of disease
Type 2 :
Poor control :
1.5yrs for every chronological year of disease
Tight control:
1.06yrs for every chronological year of disease

11. • Fasting Blood Sugar
• Postlunch Blood Sugar
• Random Blood Sugar
• Glycosylated Haemoglobin A1C
• Urine analysis

12. CLINICAL EXAMINATION
SYSTEMIC EXAMINATION COMPLICATIONS OF D.M
S
• CVS –
• peripheral vascular
disease
• CNS –R/O CVA,ANP/PNP
• Respiratory system
• Renal examination
• Fundus – Proliferative
Retinopathy
• LJM syndrome– Prayer
sign
• Thyroid /autoimmune
disorders
• Obesity
• Hyperglycemia
• Hypoglycemia
• DKA
• HNKC

13. Stiff Joint Syndrome –
Long standing type 1 DM.
Rapidly progressive microangiopathy, nonfamilial
short stature, tight waxy skin, limited joint mobility,
joint contractures.
Prayer sign.
Difficult intubation.

15. PALM PRINT GRADE –O : all phalangeal
areas are visible
GRADE-1 : deficiency in the
interphalangeal areas of the
4th &5th digits.
GRADE-2 : deficiency in
interphalangeal areas of the
2nd to 5th digits.
GRADE -3 : only the tips of
digits are seen.

16. Tests of Autonomic neuropathy:
Tests reflecting parasympathetic Neuropathy
Heart rate variation during deep breathing
Normal > 15 beats/min
Abnormal < 10 beats/min
Heart rate response to Valsalva manoeuvre
Normal > 1.21
Abnormal < 1.10
Heart rate response to standing
R-R interval of 30 th beat
-------------------------------------
R-R interval of 15 th beat
Normal >1.04
Abnormal < 1.01
•

17. Tests reflecting sympathetic Neuropathy
Blood pressure response to standing
( Fall in systolic blood pressure)
Position : lying to standing
Normal < 10 mm Hg.
Abnormal > 30 mm Hg
Blood pressure response to sustained hand grip
( increase in diastolic blood pressure )
Normal >16mm Hg.
. Abnormal < 10 mm Hg

18. Anaesthetic implications of ANP
• Postural hypotension
• Gastric atonia
• Paroxysmal diarrhoea
• Urinary retention
• Lack of premonitory signs of hypoglycemia
• Silent myocardial infarction
• Sudden death
• Poor compensation to blood loss &
sympathetic blockade

19. INVESTIGATIONS
CBP
Glycemic control : FBS, PPBS, HbA1C
Kidney function tests
CUE
Ketone bodies
S. electrolytes
BU / BUN/ S.creatinine
Cardiovascular evaluation
ECG to R/O asymptomatic IHD / MI / Ischemia
ECHO Cardiography / Dobutamine stress test /Angiography
Respiratory evaluation
X- ray chest :R/O Infection / Cardiomegaly
PFT if indicated
ABG if acidosis suspected
Fundoscopy
Appropriate evaluation in case of secondary diabetes

20. EVALUATION FOR EMERGENCY
SURGERY
Assess
• Glycemic
• Acid-base
• Electrolyte
• Fluid status
Correct any derangements before surgery.
Surgery should be delayed, if possible, to stabilize
metabolic status.

21. PREOPERATIVE PREPARATION
• Establishing good glycemic control
• Correcting any other metabolic
abnormalities
• Evaluation of organ function and
optimization of function

22. Class of Drug Dosage (mg) Duration
(hrs)
Biguinides Metformin 500-2000 12-24
Sulfonyl urea
First generation
Chlorpropamide
Tolazamide
Tolbutamide
100-500
100-1000
500-3000
>48
12-24
6-12
Second generation
Glimepiride
Glipizide
Glipizide(ER)
Glyburide
1-8
2.5-40
5-10
1.25-20
24
12-18
24
12-24
Meglitinide Repaginate 0.5-16 2-6
Glucosidase inhibitors Acarbose
Miglitol
25-100 8-10
Thiazolidenediones Rosiglitazone
Pioglitazone
1-4
15-30
10-12
12-24

23. Insulin
Lispro
Aspart
Neutral
Regular
Isophane Ultratard Glargine
Onset 10-20’ 30’ 1 h 4 h 2-4 h
Peak 1 h 1-3 h 4-6 h 6 -18 h Peakless
Duration 3-5 h 4-8 h 8 -14 h 24 h 20 -24 h

24. REGIMENS FOR
INTRAOPERATIVE GLYCEMIC
CONTROL

25. I
N
S
U
L
I
N
KETOACIDOSIS
HYPERGLYCEMIA

26. CLASSIC REGIME
TIGHT CONTROL
REGIME
• Avoid hypoglycemic
• Avoid ketoacidosis
• Avoid hyperosmolar state.

27. Various regimens for intra operative Glycemic
Control
• No insulin, No glucose regimen
• Subcutaneous insulin regimen
• I.V.Insulin regimens
– Alberti & Thomas regimen
– Modified Alberti’s regimen
– Osmania General Hospital regimen
– Vellore regimen
• Tight control regimen
– Piggy back method
– Variable insulin infusion regimen
– Artificial pancreas

28. PRE OPERATIVE INSTRUCTIONS
• Scheduled preferably as the first case for the day
• No OHA or Insulin on the morning of surgery
• NPO status of 12 hrs before surgery
• Antacid prophylaxis : H2 receptor antagonists ,
metaclopramide
• Consider Perioperative beta-blocker therapy
• On the morning of surgery
Fasting Blood glucose
S. Electrolytes
Urine sugar & ketone bodies

29. 500ml 10% D +10 U soluble insulin +
1g KCl @ 100ml/hr (2U /hr)
Monitor BS 2-4hrly / ± KCl acc. to S.K+ levels
< 90mg%
500ml10% glucose with 5U
soluble insulin + KCl @
100ml/hr
91-180mg% 181-360 mg%
10 U soluble
insulin + KCl @
100ml/hr
15U soluble insulin
+ KCl @ 100ml/hr
 360 mg%
20 U soluble
insulin + KCl @
100ml/hr
Infusion commenced on the morning of surgery
ALBERTI &THOMAS REGIMEN

30. MODIFIED ALBERTI REGIMEN
Infusion commenced on the morning of surgery
500ml 10% D +15 U soluble
insulin + 10mmol/L KCl @
100ml/hr (3U /hr)
Monitor BS 2ndhrly / ± KCl acc. to S.K+ levels
<120mg%
(6.5 mmol/L)
120 – 200mg%
(6.5-11 mmol/L)
>200mg%
(>11 mmol/L)
500ml glucose with 10U
soluble insulin
Continue same 500ml glucose with 20U
soluble insulin

31. Watts Variable Rate Insulin infusion
Blood Glucose
(mg %)
Insulin Infusion rate
<80 No insulin , 25 ml of 50% Dextrose
80 -120 Decrease by 0.3 U /hr
120 – 180 0.5 – 1 U / hr
180 – 220 Increase by 0.3 U / hr
> 220 Increase by 0.5 U / hr
25 units of regular insulin in 250 ml of normal saline (1U/10ml)
Piggyback this to infusion of 5% Dextrose and start insulin
at 0.5 U - 1 U / hr, glucose 5-10gm /hr. and K+ 2-4 mEq /hr.
Blood glucose is monitored every hour.

32. Osmania General Hospital
Regime
• Burette set connected to 500ml 5% Dextrose
• 100ml 5%D filled at a time
• HAI added acc. to the scale infused over 1 hr
• BG@1hr determines the amount of insulin
to be added to the next 100ml

33. Blood Glucose (mg %) Insulin Infusion rate
Less than 75 No insulin , 100 ml of 5% Dextrose over 15 min
75 -100 No insulin , 100 ml of 5% Dextrose over 1 hr.
100 – 125 1 U Actrapid / 100 ml 5% Dextrose over 1 hr
125 – 180 2 U Actrapid / 100 ml 5% Dextrose over 1 hr
180-250 3 U Actrapid / 100 ml 5% Dextrose over 1 hr
More than 250 4 U Actrapid / 100 ml 5% Dextrose over 1 hr
If potassium is less than 3 mmol/ L add 10 mmol of KCl to the insulin dextrose
drip
Osmania General Hospital Regime

34. Blood glucose level,
mg per dL HAI (units)
Below 100 . -
101- 150 1
151 – 200 2
201 – 250 3
251 to 300 4
301 to 350 5
351 to 400 6
> 400 8
K+ > 5 mEq/ L - NIL
4 – 5meq / L - 2 mEq / 100 ml
3 – 4 mEq / L - 4 mEq / 100ml
< 3 mEq / L - 6 mEq / 100ml
Vellore Regimen

35. Piggy back regimen :
Target blood glucose is 79 – 120 mg/d L
PPBG determined before surgery
5% Dextrose started @ 50ml/hr/70 Kg
Piggy back an infusion of regular insulin 50U in 250ml
0.9%NS with an infusion pump
Set rate is:
Insulin (U / hr) = Plasma Glucose (mg/d L)
150
Denominator is 100 if the patient is on steroids , obese
or has infection

36. Closed loop controller :
Tight control regime 2
• Same as in regime 1
• plus a feedback mechanical pancreas and
• set the desired plasma glucose regimen.

37. Management of diabetic
patients undergoing surgery:
Insulin independent diabetics:
• Minor surgery
• Major surgery

38. Insulin dependent Diabetics
EMERGENCY
SURGERY
ELECTIVE
SURGERY
CONTROLLED
DM
UNCONTROLLED
DM
CONTROLLED
DM
UNCONTROLLED
DM

39. Controlled DM Elective surgery
Minor surgery:
• Fasting blood sugar on the day of operation
• First case in the morning
• Food & insulin omitted until after operation
• When patient has recovered, he may be fluids, when
tolerating light meal and slightly less than his usual dose
of insulin after estimating blood glucose.

40. Controlled DM Elective surgery
Major surgery:
• Long acting preparation are converted to short
acting insulin twice daily.
• First on the list.
• Fasting blood sugar in the morning
• Variable dose intravenous insulin and dextrose
infusion started.
• Blood sugar monitored 2 hrly
• Postoperatively, blood sugar is estimated, insulin
adjusted .

41. Elective uncontrolled DM

42. Emergency controlled DM
• Metabolic, electrolyte and volume status
should be assessed.
• Glycemic control during Perioperative period
achieved using variable rate intravenous
insulin infusion
• Possibility of patient taking OHA or insulin
and presenting for emergency surgery must
be kept in mind.

43. Emergency uncontrolled DM
Preoperative assessment
• Metabolic status:
– immediate measurement of plasma glucose, pH, creatinine,
BUN, electrolytes , urine analysis
• Volume status:
– check for orthostasis, elevated BUN and/or creatinine, urine
output
• Cardiac status:
– ECG

44. Preoperative treatment
• Delay surgery if possible until metabolic
control and volume status are stabilized.
• Optimize glucose, electrolyte, and acid-
base status.
• Insulin and Glucose
• Saline infusion if volume is depleted
• Potassium infusion
• Bicarbonate infusion

45. INTRAOPERATIVE MONITORING
•Pulse oxymeter
•NIBP / IBP
•ECG
•Temperature
• Input /Output
•CVP/ABG if indicated
•EtCO2
•Fluid & electrolyte balance
Peripheral nerve stimulator
(SOS)
MONITORING OF
VITALS
GLYCEMIC
MONITORING &
CONTROL
Minor surgery :
BG once before surgery
once during surgery
2ndhrly postop till orals
then 8thhrly for1st 24 hrs
Major Surgery :
BG before surgery
Start Glucose, Insulin & K+
Check BG every1 to 2 hrs
Postopera tive care

46. INTRAOPERATIVE FLUIDS IN
DIABETICS:
• Dextrose solutions
• Ringer Lactate
• Saline
• Lipid containing solutions
• Potassium supplementation
• Massive blood transfusions

47. REGIONAL ANAESTHESIA
Advantages:
• Awake patient
• Lesser surgical stress response
• Excellent analgesia
• Avoids problems of difficult airway
• Less nausea & vomiting
• Can resume diet early

48. REGIONAL ANAESTHESIA
Disadvantages
• Profound hypotension in patients with
autonomic neuropathy (ANP)
• Risks of infection and nerve damage

49. Precautions during Regional
anaesthesia
• Document the pre existing neurological deficits
• Avoid adrenaline containing solutions
• Titrate local anaesthetic dosages
• Avoid Centriaxial blocks in patients with ANP

50. GENERAL ANAESTHESIA
• Aspiration prophylaxis
• Difficult airway cart kept ready
• Rapid sequence induction
• Possibility of exaggerated hypotension with IV induction in
patients with ANP
• Consider use of Perioperative beta-blocker
• Usage of short acting agents
• Good analgesia & adequate depth
• Meticulous monitoring
• Careful positioning of patients ---- care of pressure points

51. POST OPERATIVE CARE OF DIABETIC PATIENT
1. HDU (High Dependency Unit) care and monitoring
2. Adequate glycemic control:
Type 1 & 2 - Minor surgery – continue preoperative medication with diet
Major surgery -
Type 1 & Type 2 --continue Variable rate insulin infusion
Type 2 Non-insulin dependent
Stop infusion and restart OHA with diet
Type 1 Insulin dependent
Stop infusion when eating and drinking , 2hr after Sc insulin dose
Give the total daily dose of insulin as Sc Soluble insulin divided into 3 - 4 doses in
24 hours
Once stable restart normal regimen
Prep regimen may be started on 2nd or 3rd post op. day
Type 1 & Type 2

52. POST OPERATIVE CARE OF DIABETIC PATIENT
3. Good analgesia
I.V Opioids
PCA / PCEA / CEA
NSAIDS
4. DVT Prophylaxis
5. Appropriate antibiotic coverage
6. Stress ulcer prophylaxis
7. Prone for Respiratory infections , ARDS and cerebral edema
8. Chest physiotherapy, Incentive spirometry and Deep breathing exercises
Hypothermia should be avoided.
Neuropathy from long standing diabetes may manifest as
Urinary incontinence ,Urinary retention
Constipation & Gastroperisis
Evaluate end organ changes and optimize organ function.

53. Thank you