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Diabetes And Surgery Ppt

Metabolic Surgery For Type 2 Diabetes Mellitus: Experience From Asia

Metabolic Surgery For Type 2 Diabetes Mellitus: Experience From Asia

Metabolic Surgery for Type 2 Diabetes Mellitus: Experience from Asia 1Department of Surgery, Min-Sheng General Hospital, National Taiwan University, Taoyuan, Taiwan. 2Department of Surgery, Ng Teng Fong General Hospital, Singapore. Corresponding author: Wei-Jei Lee. Department of Surgery, Min-Sheng General Hospital, National Taiwan University, No 168, Chin Kuo Road, Taoyuan, Taiwan. [email protected]_grussebo_eeljw Received 2016 Sep 2; Accepted 2016 Oct 25. Copyright 2016 Korean Diabetes Association This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( ) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. This article has been cited by other articles in PMC. Type 2 diabetes mellitus (T2DM) is a current global health priority and Asia is the epicenter of this epidemic disease. Unlike in the west, where older population is most affected, the burden of diabetes in Asian countries is disproportionately high in young to middle-age adults. The incidence of diabetic nephropathy is alarmingly high in patients with early onset T2DM, especially in those with poor glycemic control. How to control this chronic and debilitating disease is currently a very important health issue in Asia. Bariatric surgery has proven successful in treating not just obesity but also T2DM in morbid obese patients (body mass index [BMI] >35 kg/m2). Gastrointestinal metabolic surgery recently has been proposed as a new treatment modality for obesity related T2DM for patients with BMI <35 kg/m2. Many studies from Asia reported promising results of metabolic surgery to treat obese patients with T2DM which is not well controlled. It has been demonstrated that Continue reading >>

Surgical Treatment Of Diabetes Mellitus By Islet Cell And Pancreas Transplantation

Surgical Treatment Of Diabetes Mellitus By Islet Cell And Pancreas Transplantation

The incidence and progression of chronic diabetic complications can be reduced by achieving normoglycaemia (box 1). Unfortunately the recent Diabetes Control and Complications Trial has shown that intensive, subcutaneous insulin regimens that improve blood glucose control puts the patient at three times the risk of developing severe hypoglycaemia.1 Intensive subcutaneous insulin regimens can never mimic the physiological fluctuations of in vivo insulin secretion. An alternative option to achieve near normoglycaemia is by transplantation of the whole pancreas (vascularised pancreas transplantation). Some would argue that this is perhaps a cumbersome approach when only the islet cells are needed to restore physiological levels of blood glucose, but perhaps more importantly pancreas transplantation (box 2) has an appreciable high rate of morbidity and mortality compared with kidney transplantation alone.2With these factors in mind investigators have tried to isolate and transplant individual islet of Langerhans cells. Box 1: Chronic diabetic complications Peripheral vascular disease. Coronary artery disease. Box 2: Pancreas transplantation Major surgical procedure. Higher rate of morbidity and mortality. Need for immunosuppression. Improves quality of life. Reverses some diabetic complications. 82% insulin independent at one year. Box 3: Islet transplantation Minor radiological procedure. Low morbidity and mortality. Intrahepatic implantation. Potential for no immunosuppression. Potential for use in young newly diagnosed diabetic patients. 14% insulin independent at one year. The advantages of islet cell transplantation (box 3) are that it requires only local anaesthesia and is a minor radiological procedure having minimal risk to the patient. Unfortunately the merits of b Continue reading >>

Jay Shubrook Do Facofp

Jay Shubrook Do Facofp

Associate Professor of Family Medicine Director, Diabetes Fellowship Ohio University Heritage College of Osteopathic Medicine Obesity and Diabetes Review the married epidemics of obesity and diabetes Review how diabetes can be prevented in obese individuals Review how you can improve obesity and diabetes simultaneously Discuss different treatments for different types of diabetes US Obesity Epidemic 17% of all US deaths from obesity approx. 300,000 deaths/year Obesity equals smoking as cause of preventable death Shortens life span 5 -22 years Extremely obese white male 20-30 Lose 13 yrs of life Mortality 12x higher if BMI >40 Years of Life Lost Due to Obesity, JAMA January 8, 2003:89;2;187-193 Obesity Greatest US health expenditure Social and ethnic differences in obesity Greater in women x 2 Greater among Black Americans Women>> men Greater among non-HS grads Largest increase in ages 19-28 75% of those with extreme obesity have a co-morbid disease 1999 Obesity Trends* Among U.S. Adults BRFSS, 1990, 1999, 2009 (*BMI 30, or about 30 lbs. overweight for 5’4†person) 2009 1990 No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30% Risk of Type 2 Diabetes as a function of BMI 0 10 20 30 40 50 60 70 80 90 100 <22 22- 22.9 23- 23.9 24- 24.9 25- 26.9 27- 28.9 29- 30.9 31- 32.9 33- 34.9 >35 Adjusted relative risk of diabetes Colditz GA et al. Ann Int Med, 1995 BMI Range Childhood Obesity in Ohio 1/3 of 3rd graders were overweight or obese Higher rates in Hispanic and Non-Hispanic Black children Children in Appalachian counties Low income children Children who watched at least 3 hours TV/day Highest in kids who drank >1 sweetened beverage per day ODH 2009-2010 data Risk Factors for Obesity Environmental Factors Portion size (market p Continue reading >>

Type 2 Diabetes And Prediabetes:

Type 2 Diabetes And Prediabetes:

A New Understanding of Cause and Treatment Endocrine Specialists Greenville Health System Objectives for this presentation Understand the “thrifty genotype and thrifty phenotype†hypothesis as to the origin of insulin receptor signaling pathway mutations in patients with type 2 diabetes Review the new hypothesis as to the cause of pre-diabetes and type 2 diabetes Understand why bariatric surgery and extreme diets can reverse type 2 diabetes - Briefly review current research for diagnosis and treatment of type 2 diabetes Types of Diabetes Type 1 diabetes – autoimmune destruction of beta cells in the islets of Langerhans in the pancreas Type 2 diabetes – chronic hyperglycemia resulting from insulin receptor signaling pathway gene mutations LADA (latent autoimmune diabetes of adulthood) Diabetes due to pancreatic destruction (pancreatitis, pancreatic resection) Other genetic causes (Leprechaunism, MODY, etc) Pre-diabetes: Two finger stick glucoses of 100-125 HbA1c 5.7-6.4 Post glucola (2hr) glucose 140-199 Diabetes: Two finger stick fasting glucoses of 126 or higher HbA1c 6.5 or higher Post glucola (2hr) glucose >200 Definition of pre-diabetes and diabetes What causes pre-diabetes and diabetes? Is it obesity? Is it genetics? Is it bad life-style? - 85 percent of diabetics are overweight - but only 30 percent of overweight people have type 2 diabetes and 15 percent of type 2 diabetics have a normal BMI The Paradox… Only two organs need insulin to internalize glucose: Skeletal muscle Fat Skeletal muscle transforms chemical energy (glucose) to mechanical work on a “as needed†basis. Fat provides free fatty acids (FFA) for conversion to ATP in mitochondria during prolonged periods of energy need or during periods of fasting. The key: bot Continue reading >>

Perioperative Management Of Blood Glucose In Adults With Diabetes Mellitus

Perioperative Management Of Blood Glucose In Adults With Diabetes Mellitus

INTRODUCTION Diabetes mellitus is a common chronic disorder, affecting approximately 8 percent of the United States population [1]. Patients with diabetes have an increased incidence of cardiovascular disease and this, combined with the frequent microvascular complications of the disease, often translate into more surgical interventions. Careful assessment of patients with diabetes prior to surgery is required because of their complexity and high risk of coronary heart disease, which may be relatively asymptomatic compared with the nondiabetic population. Diabetes mellitus is also associated with increased risk of perioperative infection and postoperative cardiovascular morbidity and mortality [2,3]. One key aspect of the perioperative management is glycemic control; complex interplay of the operative procedure, anesthesia, and additional postoperative factors such as sepsis, disrupted meal schedules and altered nutritional intake, hyperalimentation, and emesis can lead to labile blood glucose levels. A rational approach to diabetes mellitus management allows the clinician to anticipate alterations in glucose and improve glycemic control perioperatively [4]. This review will discuss the preoperative evaluation of patients with diabetes, general goals of glycemic control, and management of blood glucose in the perioperative phase. The special circumstances of glucocorticoid therapy and hyperalimentation are also reviewed. More details regarding glucose control in hospitalized patients in general are found separately. (See "Management of diabetes mellitus in hospitalized patients" and "Glycemic control and intensive insulin therapy in critical illness".) PREOPERATIVE EVALUATION Clinical evaluation — The preoperative evaluation of any patient, including those with diabet Continue reading >>

Precautions For Patients With Diabetes Undergoing Surgery

Precautions For Patients With Diabetes Undergoing Surgery

Professional Reference articles are written by UK doctors and are based on research evidence, UK and European Guidelines. They are designed for health professionals to use. You may find the Type 1 Diabetes article more useful, or one of our other health articles. There is a rising incidence and prevalence of diabetes mellitus. About 50% of people with diabetes mellitus are unaware of their condition. Approximately 25% of all patients with diabetes undergoing surgery are undiagnosed on admission to hospital. Patients with diabetes have a higher risk of cardiovascular disease. Patients with diabetes have a higher perioperative risk. They are more likely because of their disease to require surgery and those undergoing surgery are likely to be less well controlled and to have complications from their diabetes. Surgeons and anaesthetists operating on patients with diabetes should be familiar with the risks attached to having diabetes, and to the particular risks of the particular surgery and of anaesthesia in patients with diabetes. Risks and complications of diabetes mellitus Patients with diabetes mellitus are at risk of the complications of the disease. It is worth considering these in outline when considering how best to care for patients with diabetes undergoing surgery. See also separate Diabetes Mellitus article. Perioperative risks and complications of diabetes mellitus It is important in assessing risk of complications in patients with diabetes undergoing surgery to consider the specific type of surgery and anaesthetic technique. There is evidence for higher risk in those with diabetes undergoing surgery and, when such evidence is lacking, it may in part be testament to the relative safety of modern surgery and anaesthesia. However, the following risks and observati Continue reading >>

Perioperative Management Of The Diabetic Patient

Perioperative Management Of The Diabetic Patient

Perioperative Management of the Diabetic Patient Author: Mira Loh-Trivedi, PharmD; Chief Editor: William A Schwer, MD more... Diabetes mellitus (DM) is an increasingly common medical condition affecting approximately 8% of the population of the United States. Of these 25 million people, it is estimated that nearly 7 million are unaware that they have the disease until faced with associated complications. [ 1 , 2 ] The prevalence of DM is even greater in hospitalized patients. The American Diabetes Association conservatively estimates that 12-25% of hospitalized adult patients have diabetes mellitus (DM). With the increasing prevalence of diabetic patients undergoing surgery, and the increased risk of complications associated with diabetes mellitus, appropriate perioperative assessment and management are imperative. An estimated 25% of diabetic patients will require surgery. Mortality rates in diabetic patients have been estimated to be up to 5 times greater than in nondiabetic patients, often related to the end-organ damage caused by the disease. Chronic complications resulting in microangiopathy (retinopathy, nephropathy, and neuropathy) and macroangiopathy (atherosclerosis) directly increase the need for surgical intervention and the occurrence of surgical complications due to infections and vasculopathies. [ 3 , 4 , 5 , 6 ] Infections account for 66% of postoperative complications and nearly one quarter of perioperative deaths in patients with DM. Data suggest impaired leukocyte function, including altered chemotaxis and phagocytic activity. Tight control of serum glucose is important to minimize infection. In addition to postoperative infectious complications, postoperative myocardial ischemia is increased among patients with DM undergoing cardiac and noncardiac su Continue reading >>

Diabetes Emergencies And Management Of Surgery

Diabetes Emergencies And Management Of Surgery

Diabetic Ketoacidosis Definition Hyperglycaemia (use capillary sample but confirm with lab test) Venous bicarbonate less than 15 mmol/l Ketonaemia (if in doubt about cause of acidosis test urine or plasma with ketostix) Causes older age groups- infections < 30y omission of insulin Mortality: 5-10% ?lower in specialist centres Causes Elderly associated co-morbidity and late diagnosis Young severe DKA recognised late a failure to monitor patients and follow guidelines rare and poorly understood condition of cerebral oedema in children. Diabetic Ketoacidosis Pathophysiology (1) lack of insulin and/or rising levels of glucagon, adrenaline, cortisol leads to rising glucose levels from gluconeogenesis lipolysis raises NEFA and glycerol. Liver oxidises NEFA to form acetyl coA and then ketone bodies High glucose overcomes capacity of the kidney to reabsorb glucose, glycosuria inhibits water reabsorption and losses of potassium, sodium + other electrolytes Pathophysiology (2) Compensation for urinary losses by drinking maintains circulating blood volume Rise in ketones and increasing acidaemia leads to anorexia and vomiting, a critical point Circulating blood volume falls due to obligatory urinary losses from osmotic effect of urinary glucose Principles of DKA management a potentially lethal condition, treatment should be started with 30 min of admission Restore circulating blood volume Replace lost electrolytes Return blood glucose towards normal while giving sufficient insulin to inhibit hepatic production of ketones Acidosis will correct itself if the above treatment is delivered appropriately Investigations Venous blood for: Urea and electrolytes Blood glucose Full blood count Venous bicarbonate Blood cultures Consider: Arterial blood gases- only if you suspect hypoxia. Ches Continue reading >>

Perioperative Diabetes Mellitus Management

Perioperative Diabetes Mellitus Management

1. PERIOPERATIVE MANAGEMENT OF DIABETES MELLITUS SPEAKER Dr. DHARMRAJ SINGH MODERATOR Dr. SHASHI PRAKASH 2. INTRODUCTION  Patients with diabetes have higher incidence of morbidity and mortality.  Poor peri-operative glycaemic control increases the risk of adverse outcomes.  Treatment of post-operative hyperglycaemia reduces the risk of adverse outcomes. 3. CRITERIA FOR DIAGNOSIS OF DIABETES 1. Symtoms of diabetes plus random plasma glucose level >200 mg/dL (11.1 mmol/L) 2. Hemoglobin A1C ≥ 6.5 % 3. Fasting plasma glucose level ≥ 126 mg/dL (7.0 mmol/L) 4. Two-hour plasma glucose level ≥ 200 mg/dL (11.1 mmol/L) American Diabetes Association 4. METABOLIC SYNDROME At least three of the following  Fasting plasma glucose ≥ 110 mg/dl  Abdominal obesity (waist girth > 40 [in men], 35 [in women])  Serum triglycerides ≥ 150mg/dl  Serum HDL cholesterol < 40 mg/dl (men), <50 (women)  BP ≥ 130/85 mm Hg  Insulin-resistant syndrome is a constellation of clinical & biochemical characteristics frequently seen in pt with or at risk of type 2 diabetes. 5. THE METABOLIC RESPONSE TO SURGERY AND THE EFFECT OF DIABETES Metabolic effects of starvation: 1. Period of starvation induces a catabolic state. 2. It will stimulate secretion of counter-regulatory hormones . 3. It can be attenuated in patients with diabetes by infusion of insulin and glucose (approximately 180g/day). Metabolic effects of major surgery. It causes neuroendocrine stress response with release of counter- regulatory hormones (epinephrine, glucagon, cortisol and growth hormone) and of inflammatory cytokines IL-6 and tumor necrosis factor-alpha. 6. CONTD… Hypoglycaemia – exacerbate the catabolic effect of surgery These neuro hormonal changes result in metabolic abnormaliti Continue reading >>

Management Of Diabetes In Surgery

Management Of Diabetes In Surgery

To view this video please enable JavaScript, and consider upgrading to a web browser that supports HTML5 video Published by Mia Watkins Modified over 4 years ago Presentation on theme: "Management of Diabetes in Surgery" Presentation transcript: 2 Diabetes Diabetes is a metabolic disorder resulting from insulin deficiency or intolerance Associated with acute and long term systemic problems Diagnosed by a random plasma glucose >11.1mmol/l and a fasting glucose>7.0mmol/l (WHO criteria) The two most common forms of diabetes are Insulin Dependant Diabetes Mellitus (Type 1) and Non Insulin Dependant Diabetes Mellitus (Type 2) Polygenic disorder thought to be of auto immune aetiology Results in destruction of cells in the Islets of Langerhans in the Pancreas, with subsequent insulin deficiency Young onset 0.4% prevalence Endogenous insulin is required to maintain plasma glucose levels to within physiological levels Hypoglycaemia resulting from reduced insulin secretion and peripheral insulin resistance Some genetic concordance Older onset, associated with central obesity Depending on severity, may be controlled with: diet and exercise to lose weight oral hypoglycaemics insulin 5 Diabetes and Surgery Surgery is a form of physical trauma It results in catabolism, increased metabolic rate, increased fat and protein breakdown, glucose intolerance and starvation. In a diabetic patient, the pre existing metabolic disturbances are exacerbated by surgery The type of diabetes, amount of insulin dose, diet or oral hypoglycaemic agents must be considered as this will change the overall management plan The risk of significant end-organ damage increases with the duration of diabetes, although the quality of glucose control is more important than the absolute time 6 Factors Adversely Affe Continue reading >>

Perioperative Hyperglycemia Management: An Update

Perioperative Hyperglycemia Management: An Update

During the fasting state, normal subjects maintain plasma glucose levels between 60 and 100 mg/dl (3.3 to 5.5 mM). The stress of surgery and anesthesia alters the finely regulated balance between hepatic glucose production and glucose utilization in peripheral tissues. An increase in the secretion of counterregulatory hormones (catecholamines, cortisol, glucagon, and growth hormone) occurs, causing excessive release of inflammatory cytokines including tumor necrosis factor-α, interleukin-6, and interleukin-1β (fig. 1). Cortisol increases hepatic glucose production, stimulates protein catabolism, and promotes gluconeogenesis, resulting in elevated BG levels. Surging catecholamines increase glucagon secretion and inhibit insulin release by pancreatic β cells. Additionally, the increase in stress hormones leads to enhanced lipolysis and high FFA concentrations. Increased FFAs have been shown to inhibit insulin-stimulated glucose uptake and limit the intracellular signaling cascade in skeletal muscle responsible for glucose transport activity. Evidence also suggests that tumor necrosis factor-α interferes with the synthesis and/or translocation of the glucose transporter-4 receptor, reducing glucose uptake in peripheral tissues. These processes result in an altered state of insulin action, leading to a relative state of insulin resistance, which is most pronounced on the first postoperative day and may persist for 9 to 21 days after surgery. Continue reading >>

Management Of Diabetes Mellitus In Surgical Patients

Management Of Diabetes Mellitus In Surgical Patients

Abstract In Brief Diabetes is associated with increased requirement for surgical procedures and increased postoperative morbidity and mortality. The stress response to surgery and the resultant hyperglycemia, osmotic diuresis, and hypoinsulinemia can lead to perioperative ketoacidosis or hyperosmolar syndrome. Hyperglycemia impairs leukocyte function and wound healing. The management goal is to optimize metabolic control through close monitoring, adequate fluid and caloric repletion, and judicious use of insulin. Patients with diabetes undergo surgical procedures at a higher rate than do nondiabetic people.1,2 Major surgical operations require a period of fasting during which oral antidiabetic medications cannot be used. The stress of surgery itself results in metabolic perturbations that alter glucose homeostasis, and persistent hyperglycemia is a risk factor for endothelial dysfunction,3 postoperative sepsis,4 impaired wound healing,5,6 and cerebral ischemia.7 The stress response itself may precipitate diabetic crises (diabetic ketoacidosis [DKA], hyperglycemic hyperosmolar syndrome [HHS]) during surgery or postoperatively, with negative prognostic consequences.8,9 HHS is a well known postoperative complication following certain procedures, including cardiac bypass surgery, where it is associated with 42% mortality.9,10 Furthermore, gastrointestinal instability provoked by anesthesia, medications, and stress-related vagal overlay can lead to nausea, vomiting, and dehydration. This compounds the volume contraction that may already be present from the osmotic diuresis induced by hyperglycemia, thereby increasing the risk for ischemic events and acute renal failure. Subtle to gross deficits in key electrolytes (principally potassium, but also magnesium) may pose an arrhy Continue reading >>

Surgery In Diabetes Mellitus

Surgery In Diabetes Mellitus

Surgery In Diabetes Mellitus (DM) Walid Sayed Abdelkader Hassanen Specialist of internal Medicine * Hyperglycemia leads to impaired wound healing , deficient formation of granulation tissue. The chemotactic , phagocytic, and bacterial activity of the neutrophil is deficient , there is impaired hormonal host defense mechanism and abnormal complement function. * Metabolic sequelae in a surgical patient Increased glycogenolysis Increased gluconeogenesis hyperglycemia Decreased glucose utilization: Lipolysis with increased FFA Protein breakdown Increased nitrogen loss Increased urea production Increased sodium retension & potassium execretion and alteration of water metabolism ( increased ADH and increased aldosterone secretion ) free fatty acid (FFA) Antidiuretic hormone (ADH) * * Determinents of the management plan Type of DM Treatment, diet, oral antidiabetic drugs, insulin Metabolic status Vascular status: cardiac, renal, cerebral Surgery: Type: emergency or elective Minor or major procedure Type of anesthesia Post operative oral intake Pre-operative management Metabolic stress of surgery and anesthesia cause increased elaboration of catecholamins, glucocorticoids, glucagon, and growth hormone, all producing their metabolic effects resulting in hyperglycemia in the pre-operative period. The glycemic control is aimed to achieve a fasting plasma glucose of < 140 mg % and post prandial plasma glucose of < 200 mg %. Insulin dependent diabetic patients can be admitted 2-3 days prior to surgery to achieve satisfactory control. Cont. In NIDDM patients if the control is good with oral antidiabetic drugs , these drugs are stopped on the day of the surgery and intravenous fluids and insulin are given , if not are advised to stop drugs one week before surgery and admitted for insu Continue reading >>

Reference

Reference

This purpose of this talk is to overview the 2017 American Diabetes Association Standards of Medical Care in Diabetes. These Standards comprise all of the current and key clinical practice recommendations of the American Diabetes Association. [SLIDE] 2 Reference American Diabetes Association. Standards of medical care in diabetes—2014. Diabetes Care 2014;37(suppl 1):S1 A few notes on the Standards of Care: The Association funds development of the Standards of Care and all Association position statements out of its general revenues and does not use industry support for these purposes [CLICK] The slides are organized to correspond with sections within the 2017 Standards of Care. As we go through I’ll make note of where we are within the document. [CLICK] Though not every section in the document is represented, these slides do incorporate the most salient points from the Position Statement As with all Association position statements, the Standards of Care are reviewed and approved by the Association’s Board of Directors, which includes health care professionals, scientists, and lay people. [SLIDE] 3 These Standards of Care are revised annually by the ADA’s multidisciplinary Professional Practice Committee (PPC) [CLICK] For the 2017 revision, PPC members systematically searched Medline for human studies related to each subsection and published since 1 January 2016. [CLICK] Recommendations were revised based on new evidence or, in some cases, to clarify the prior recommendations or match the strength of the word to the strength of the evidence [CLICK] A table linking the changes in the recommendations to new evidence can be reviewed at professional.diabetes.org/SOC (Standards of Care) [CLICK] The Association and the Professional Practice Committee Continue reading >>

Guidelines For Perioperative Management Of The Diabetic Patient

Guidelines For Perioperative Management Of The Diabetic Patient

Surgery Research and Practice Volume 2015 (2015), Article ID 284063, 8 pages 1Texas A&M Health Science Center, 8447 State Highway 47, Bryan, TX 77807, USA 2Division of Pulmonary, Critical Care & Sleep Medicine, Texas A&M Health Science Center, Corpus Christi, 1177 West Wheeler Avenue, Suite 1, Aransas Pass, TX 78336, USA Academic Editor: Roland S. Croner Copyright © 2015 Sivakumar Sudhakaran and Salim R. Surani. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Abstract Management of glycemic levels in the perioperative setting is critical, especially in diabetic patients. The effects of surgical stress and anesthesia have unique effects on blood glucose levels, which should be taken into consideration to maintain optimum glycemic control. Each stage of surgery presents unique challenges in keeping glucose levels within target range. Additionally, there are special operative conditions that require distinctive glucose management protocols. Interestingly, the literature still does not report a consensus perioperative glucose management strategy for diabetic patients. We hope to outline the most important factors required in formulating a perioperative diabetic regimen, while still allowing for specific adjustments using prudent clinical judgment. Overall, through careful glycemic management in perioperative patients, we may reduce morbidity and mortality and improve surgical outcomes. 1. Introduction Diabetes has classically been defined as a group of metabolic diseases characterized by hyperglycemia due to defects in insulin secretion, insulin action, or a combination of both [1]. The vast majority of di Continue reading >>

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