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Diabetes

Created: 27/4/2004
 
  • Multi-system disease severity related to blood sugar control
  • 2% prevalence
  • Absence of insulin: type I
  • Older patients with some insulin (obese): type II. Usually treated with oral hypoglycaemic agents
  • Surgery related to the complications: sepsis, skin ulceration, peripheral vascular disease

Complications

  • Vascular: ischaemic heart disease and cerebrovascular complications. Hypotension poorly tolerated
  • Hypertension: strongest correlate of autonomic neuropathy. Autonomic neuropathy may result in sudden tachycardia with hypotension and cardiac arrest. Also causes delayed gastric emptying and risk of aspiration
  • Cardiomyopathy: leading to left ventricular dysfunction
  • Nephropathy: increased risk of renal failure and microalbuminaemia
  • Infection: sepsis is a major cause of perioperative morbidity
  • Respiratory system: decreased forced expiratory volume in one second and forced
    vital capacity, higher incidence of chest infections and chronic obstructive
    airways disease, particularly in obese patients
  • Retinopathy: high risk of vitreous haemorrhage during hypertensive procedures
  • Medical conditions: hyperpituitarism, hyperthyroidism, obesity, stress, pregnancy
  • Drugs causing diabetes: corticosteroids

Assessment

  • Assess diabetic control - delay surgery in poorly controlled patients, unless life saving
  • Orthostatic hypotension and reduced heart rate in response to Valsalva manoevre suggest autonomic neuropathy
  • Major surgery: insulin, glucose, potassium
  • Type I patients: no long-acting insulin but should be managed on subcutaneous or sliding scale
  • Type II minor surgery: omit morning oral hypoglycaemic agent and measure BM regularly
  • Ideally, these patients should be first on the surgical list

Diabetic ketoacidosis

  • Large volume resuscitation with normal saline
  • IV insulin infusion administered according to a sliding scale
  • Central venous line, urine output, acidosis, BM and potassium measured hourly
  • Large amounts of potassium can be needed
  • Allow surgery once biochemical improvement
  • Some surgical conditions need to be treated to allow control

Conduct

  • Gastric stasis: rapid sequence induction is necessary
  • Avoid lactate containing solutions such as Hartmann's (lactate is converted to bicarbonate)
  • Regional technique?? (document neuropathy)
  • Avoid hypotension and myocardial depression
  • BM 7-10 mmol/L
  • Mild hyperventilation may be beneficial

Postoperative phase

  • Continue monitoring of BM

ArticleDate:20040427
SiteSection: Article
 
   
    
                                            
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