Objectives
Avoid excess morbidity and mortality
Prevent
- Hypo, hyperglycemia, increased protein catabolism and undue electrolyte imbalance.
- Aim for a blood sugar around 200mg/dl i.e: (7 to 11 mmol/L)
- More stringent the control, better it is i.e: 110 in post op period
Pre Operative Management
General Measures:
- CVS
- Neurological:
- Renal:
- GIT:
Metabolic Assessment:
Type 1: start short acting or split insulin. Stop long acting preparations
Type 2: Stop long acting sulphonylureas, substitute with short acting ones. Stop metformin. Stop all oral hypoglycemics on the day of surgery
Peri Operative Management
Type 1:
continued Insulin Pump (IP) infusion or Glucose Insulin Potassium (GIK) infusion.
Type 2:
Minor surgery: just monitor
Major Surgery: manage as type 1
Post Operative Management
- Monitor B.S 1-2 hourly till stable glycemic control and then 4 hourly
- Check Potassium 6 hourly
- IP/GIK continued until pt begins to eat
- Overlap SC insulin for 1 hour with GIK to allow absorption of SC insulin.
Special Situations
Day Surgery
- Rx as minor surgery with meticulous control of sugar 1 hourly peri operatively
- Give SC insulin post operatively.
Emergency Surgery
Rx as major surgery with infusion (IP/GIK)
Summary and Conclusion
- Stress increases sugar
- Controlled type 2: hold Rx for minor surgery
- Un controlled type 2 + Type 1 on minor list + Type 1 on major list: Rx with IP/GIK infusion.
- OPD surgery is safe
- Emergency Surgery: good control mandatory before start of surgery
GIK
Protocol A:
30 units R insulin + 20 mmol K + 1000 ml 20% dextrose @ 100 ml/hour.
Protocol B:
15 units R insulin + 20 mmol K + 1000 ml 5% dextrose @ 100 ml/hour.
Insulin Pump
50 units R insulin + 50 ml 0.9% saline in 50 ml syringe
Infusion rate:
- 0 – 4 = 0.5 u/hr (recheck in 30 mints)
- 4.1 – 7 = 1.0
- 7.1 – 11.0 = 2.0
- 11.1 – 17.0 = 4.0
- More than 17.0 = 6.0 to 8.0
