Diabetic Control in Surgical Patients

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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

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