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Perioperative Diabetes Management

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 Diabetic Patients: New Controversies

Perioperative Management Of Diabetic Patients: New Controversies

The prevalence of diabetes mellitus (DM) is increasing rapidly. In 2011, it was estimated that 366 million people worldwide had DM with a projected increase to 522 million by 2030. Diabetes is one of the most common non-communicable diseases and is ranked as one of the top five global causes of premature death. The costs of treating DM are an increasing burden on healthcare budgets. For example, the NHS annual spending on DM was 9.8 billion in 2012 with an expected increase to 16.9 billion in the next 25 yr (17% of the total NHS budget). 1 Diabetes affects 45% of the UK population. However, the recent National Diabetes Inpatient Audit (NaDIA) found an inpatient prevalence of DM ranging from 5.5% to 31.1% within the UK. 2 Diabetes was associated with increased in-hospital morbidity and consequently increased duration of hospital stay, regardless of medical speciality. This confirms previous work showing a significantly increased duration of hospital stay in diabetic patients undergoing surgery. 3 The primary aim of perioperative management of the surgical diabetic patient is to decrease morbidity and hopefully reduce the duration of hospital stay. Two authoritative publications, one by the National Health Services Diabetes in the UK 4 and the other by the Society for Ambulatory Anesthesia (SAMBA) in the USA, 5 have provided clear guidelines that are intended to improve perioperative care. The former describes an ideal pathway for all diabetic patients undergoing elective surgery: primary care referral, surgical outpatients, preoperative assessment, hospital admission, theatre and recovery, postoperative care, and discharge. Although this pathway will be a valuable standard for elective surgery, there is limited recognition in the guidelines that urgent and emergency sur Continue reading >>

Perioperative Management Of Patients With Diabetes

Perioperative Management Of Patients With Diabetes

Hyperglycemia has long been recognized to have detrimental effects on postoperative outcomes in patients undergoing surgery. The manifestations of uncontrolled diabetes are manifold and can include risk of hyperglycemic crises, postoperative infection, poor wound healing, and increased mortality. There is substantial literature supporting the role of diligent glucose control in the prevention of adverse surgical outcomes, but considerable debate remains as to the optimal glucose targets. Hence, most organizations advocate the avoidance of hypoglycemia while striving for adequate glucose control in the perioperative period. These objectives can be accomplished with careful preoperative evaluation, clear patient instructions the day of surgery, frequent blood glucose monitoring during the perioperative period, and use of effective strategies for insulin initiation and titration. This article highlights the major issues concerning patients with diabetes undergoing surgery and reviews the management recommendations put forth by general consensus guidelines and expert opinion. Patients with diabetes requiring surgery can present a challenge to the managing clinician. With the prevalence of diabetes in the United States reaching approximately 8% of the population,1 it is now commonplace to encounter patients with diabetes presenting for surgery. Suboptimal diabetes control has been associated with adverse perioperative outcomes such as metabolic derangements, infection, poor wound healing, and increased mortality.2–6 This review article draws from several existing medical and anesthesia guidelines to provide a concise summary of diabetes treatment strategies aimed at reducing perioperative risk. Glucose metabolism is primarily orchestrated by the interplay of insulin and th Continue reading >>

13. Diabetes Care In The Hospital

13. Diabetes Care In The Hospital

Consider performing an A1C on all patients with diabetes or hyperglycemia admitted to the hospital if not performed in the prior 3 months. C Insulin therapy should be initiated for treatment of persistent hyperglycemia starting at a threshold ≥180 mg/dL (10.0 mmol/L). Once insulin therapy is started, a target glucose range of 140–180 mg/dL (7.8–10.0 mmol/L) is recommended for the majority of critically ill patients A and noncritically ill patients. C More stringent goals, such as 110–140 mg/dL (6.1–7.8 mmol/L) may be appropriate for selected critically ill patients, as long as this can be achieved without significant hypoglycemia. C Intravenous insulin infusions should be administered using validated written or computerized protocols that allow for predefined adjustments in the insulin infusion rate based on glycemic fluctuations and insulin dose. E A basal plus bolus correction insulin regimen is the preferred treatment for noncritically ill patients with poor oral intake or those who are taking nothing by mouth. An insulin regimen with basal, nutritional, and correction components is the preferred treatment for patients with good nutritional intake. A The sole use of sliding scale insulin in the inpatient hospital setting is strongly discouraged. A A hypoglycemia management protocol should be adopted and implemented by each hospital or hospital system. A plan for preventing and treating hypoglycemia should be established for each patient. Episodes of hypoglycemia in the hospital should be documented in the medical record and tracked. E The treatment regimen should be reviewed and changed if necessary to prevent further hypoglycemia when a blood glucose value is <70 mg/dL (3.9 mmol/L). C There should be a structured discharge plan tailored to the individual p 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 >>

An Update On Perioperative Management Of Diabetes

An Update On Perioperative Management Of Diabetes

Surgery in the patient with diabetes mellitus is relatively common, as the numbers of persons with diabetes is increasing and diabetes predisposes to medical conditions that require surgical intervention. An estimated 25% of diabetic patients will require surgery, and advances in perioperative care of these patients allow them to safely undergo the most complicated surgical procedures. We will review issues of preoperative, intraoperative, and postoperative care of diabetic patients. Today, advances in perioperative management have enabled diabetic patients to undergo complex surgery with increasing safety1- 4 such that more surgery is performed in an outpatient setting, and for those performed on an inpatient basis, the length of hospital stay is being shortened dramatically. This creates a logistical challenge to the perioperative treatment of the patient with diabetes mellitus. Many factors are involved in determining the glycemic response to a surgical procedure; although some may be adequately anticipated, others are very difficult to predict. Insulin secretory capability, insulin sensitivity, overall metabolism, and nutritional intake may change radically from the preoperative period through to the postoperative recuperation and may also differ greatly from one procedure to another. For this reason many physicians tend to be reactive as opposed to proactive in their management of hyperglycemia in surgical patients with diabetes. Nevertheless, marked hyperglycemia in the patient with diabetes should be prevented, as it may lead to dehydration and electrolyte abnormalities, impair wound healing, and predispose to infection or diabetic ketoacidosis in the patient with type 1 diabetes mellitus.5,6 The operative risk assessment of the patient with diabetes mellitus (Ta Continue reading >>

Guidelines For Perioperative Management Of The Diabetic Patient

Guidelines For Perioperative Management Of The Diabetic Patient

Go to: 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 diabetic cases can be classified as either type 1 or type 2 diabetes. Type 1 diabetes is generally due to β-cell destruction leading to absolute insulin deficiency. This form accounts for roughly 5–10% of diabetic cases, and individuals at increased risk can often be identified by evidence of autoimmune pathologic processes occurring at the pancreatic islets [1]. Type 2 diabetes is characterized by a progressive insulin secretory defect within a setting of insulin resistance [2]. Approximately 90–95% of diabetic cases are type 2 [1]. Management of glycemic levels in diabetic patients is critical, as persistent hyperglycemia may lend itself to a number of complications including cardiovascular disease, nephropathy, retinopathy, neuropathy, and various foot pathologies [2]. The prevalence and diagnostic criteria for diabetes are well defined. There are approximately 29.1 million people with diabetes in the United States (roughly 9.3% of the total population). Of these 29.1 million cases, around 27% or 8.1 million cases are undiagnosed [3]. Furthermore, a study funded by the World Health Organization (WHO) found that estimated 347 million people worldwide have diabetes [4]. Between 2010 and 2030, a 69% increase in the number of adults with diabetes in developing countries and a 20% increase in developed countries are predicted [5]. A diagnosis of diabetes may be confirmed through several different techniques. These diagnostic criteria include (1) hemoglobin A1c (A1c) ≥ 6.5%, (2) fasting plasma glucose ≥ 126 mg/dL (fasting is defined as no Continue reading >>

Diabetes, Surgery And Medical Illness

Diabetes, Surgery And Medical Illness

Peri-operative management of blood-glucose concentrations depends on factors including the required duration of fasting, timing of surgery (morning or afternoon), usual treatment regimen (insulin, antidiabetic drugs or diet), prior glycaemic control, other co-morbidities, and the likelihood that the patient will be capable of self-managing their diabetes in the immediate post-operative period. All patients should have emergency treatment for hypoglycaemia written on their drug chart on admission. Note: The following recommendations provide general guidance for the management of diabetes during surgery. Local protocols and guidelines should be followed where they exist. Elective surgeryminor procedures in patients with good glycaemic control Patients usually treated with insulin who have good glycaemic control (HbA1c less than 69mmol/mol or 8.5%) and are undergoing minor procedures, can be managed during the operative period by adjustment of their usual insulin regimen, which should be adjusted depending on the type of insulin usually prescribed, following detailed local protocols (which should also include intravenous fluid management, monitoring and control of electrolytes and avoidance of hyperchloraemic metabolic acidosis). On the day before the surgery, the patients usual insulin should be given as normal, other than once daily long-acting insulin analogues, which should be given at a dose reduced by 20%. Elective surgerymajor procedures or poor glycaemic control Patients usually treated with insulin, who are either undergoing major procedures (surgery requiring a long fasting period of more than one missed meal) or whose diabetes is poorly controlled, will usually require a variable rate intravenous insulin infusion (continued until the patient is eating/drinking 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 >>

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 >>

My Site - Chapter 16: In-hospital Management Of Diabetes

My Site - Chapter 16: In-hospital Management Of Diabetes

Hyperglycemia is common in hospitalized patients, even in those without a previous history of diabetes, and is associated with increased in-hospital complications, length of hospital stay and mortality. Insulin is the most appropriate agent for effectively controlling glycemia in-hospital. A proactive approach to management using scheduled basal, bolus and correction (supplemental) insulin is the preferred method. The use of sliding-scale insulin (SSI), which treats hyperglycemia after it has occurred, should be discouraged. For the majority of noncritically ill patients treated with insulin, preprandial blood glucose (BG) targets should be 5.0 to 8.0 mmol/L, in conjunction with random BG values <10.0 mmol/L, as long as these targets can be safely achieved. For critically ill patients, BG levels should be maintained between 8.0 and 10.0 mmol/L. Diabetes increases the risk for disorders that predispose individuals to hospitalization, including cardiovascular disease, nephropathy, infection, cancer and lower-extremity amputations. In-hospital hyperglycemia is common. Umpierrez etal. (1) reviewed the medical records of over 2000 adult patients admitted to a community teaching hospital in the United States (>85% were non-intensive care unit [non-ICU] patients) and found that hyperglycemia was present in 38% of patients. Of these patients, 26% had a known history of diabetes, and 12% had no history of diabetes prior to admission (1) . Diabetes has been reported to be the fourth most common comorbid condition listed on all hospital discharges (2) . Acute illness results in a number of physiological changes (e.g. increases in circulating concentrations of stress hormones) or therapeutic choices (e.g. glucocorticoid use) that can exacerbate hyperglycemia. Hyperglycemia, in tur Continue reading >>

Perioperative Management Of The Patient With Diabetes Requiring Emergency Surgery

Perioperative Management Of The Patient With Diabetes Requiring Emergency Surgery

About 100000 emergency surgical procedures are performed per annum in the UK on patients with diabetes. Diabetes is a recognized factor for a patient to become the higher risk surgical patient. The emergency surgical patient with diabetes requires meticulous initial assessment and planning to allow the diabetes, the diabetes medication and any other associated comorbidity to be optimally managed. A number of modifiable risk-factors have been identified, and by optimizing these modifiable risk factors, outcomes can be improved. For the majority of patients, the variable rate i.v. insulin infusion (VRIII) is required to control the diabetes and maintain optimal glycaemic control of 610 mmol litre1. When and where possible, the patient with diabetes requiring expedited surgery should be managed by simple manipulation of their diabetes medication. The goal of the intraoperative care/anaesthetic technique is to promote early resumption of eating and drinking and return to normal medication, whilst simultaneously preventing morbidity from glycaemic variability, acute kidney injury (AKI), fluid, and electrolyte imbalance amongst other complications. Diabetes is the most common metabolic disorder, affecting at least 67% of people in the UK. The most recent data from the National Diabetes Inpatient Audit showed that in 2013 the prevalence of diabetes in the UK in-patient hospital population ranged from 10 to 35%. 1 Diabetes-related co-morbidities increase the need for surgical and other operative procedures, thus at least 10% of patients undergoing emergency surgery have diabetes. Diabetes leads to increased morbidity, mortality, and increased length of stay whatever the admission specialty, thereby increasing costs of inpatient care. 2 The perioperative mortality rate for peop 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 >>

Perioperative Management Of Diabetes

Perioperative Management Of Diabetes

Maintaining glycemic and metabolic control is difficult in diabetic patients who are undergoing surgery. The preoperative evaluation of all patients with diabetes should include careful screening for asymptomatic cardiac or renal disease. Frequent self-monitoring of glucose levels is important in the week before surgery so that insulin regimens can be adjusted as needed. Oral agents and long-acting insulin are usually discontinued before surgery, although the newer long-acting insulin analog glargine may be appropriately administered for basal insulin coverage throughout the surgical period. The usual regimen of sliding scale subcutaneous insulin for perioperative glycemic control may be a less preferable method because it can have unreliable absorption and lead to erratic blood glucose levels. Intravenous insulin infusion offers advantages because of the more predictable absorption rates and ability to rapidly titrate insulin delivery up or down to maintain proper glycemic control. Insulin is typically infused at 1 to 2 U per hour and adjusted according to the results of frequent blood glucose checks. A separate infusion of dextrose prevents hypoglycemia. Potassium is usually added to the dextrose infusion at 10 to 20 mEq per L in patients with normal renal function and normal preoperative serum potassium levels. Frequent monitoring of electrolytes and acid-base status is important during the perioperative period, especially in patients with type 1 diabetes because ketoacidosis can develop at modest levels of hyperglycemia. Diabetic patients who require surgery present special challenges in perioperative management. Special attention must be paid to prevention and treatment of metabolic derangements. Vigilance for the development of acute complications that lead to hig Continue reading >>

Evaluation And Perioperative Management Of Patients With Diabetes Mellitus. A Challenge For The Anesthesiologist

Evaluation And Perioperative Management Of Patients With Diabetes Mellitus. A Challenge For The Anesthesiologist

Abstract Diabetes mellitus (DM) is characterized by alteration in carbohydrate metabolism, leading to hyperglycemia and increased perioperative morbidity and mortality. It evolves with diverse and progressive physiological changes, and the anesthetic management requires attention regarding this disease interference in multiple organ systems and their respective complications. Patient's history, physical examination, and complementary exams are important in the preoperative management, particularly glycosylated hemoglobin (HbA1c), which has a strong predictive value for complications associated with diabetes. The goal of surgical planning is to reduce the fasting time and maintain the patient's routine. Patients with Type 1 DM must receive insulin (even during the preoperative fast) to meet the basal physiological demands and avoid ketoacidosis. Whereas patients with Type 2 DM treated with multiple injectable and/or oral drugs are susceptible to develop a hyperglycemic hyperosmolar state (HHS). Therefore, the management of hypoglycemic agents and different types of insulin is fundamental, as well as determining the surgical schedule and, consequently, the number of lost meals for dose adjustment and drug suspension. Current evidence suggests the safe target to maintain glycemic control in surgical patients, but does not conclude whether it should be obtained with either moderate or severe glycemic control. O diabetes melito (DM) é caracterizado por alteração no metabolismo de carboidratos que leva à hiperglicemia e ao aumento da morbimortalidade perioperatória. Cursa com alterações fisiológicas diversas e progressivas e, para o manejo anestésico, deve-se atentar para a interferência dessa doença nos múltiplos sistemas orgânicos e suas respectivas complicaç Continue reading >>

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