Howard County General Hospital
HOW CAN YOU HELP prior to your surgery? Bring all of your current medications to orientation for review. Consult your physician for special instructions if you are taking routine medications, insulin, or blood thinners. Do not eat or drink anything for at least eight hours before your scheduled surgery. Do not chew gum or use any tobacco products. Leave jewelry and other valuables at home. Take out removable teeth prior to transfer to the operating room and do not wear glasses or contact lenses in the OR. If you are a Same Day Surgery patient, arrange for a responsible adult to drive you home and to provide care for at least 24 hours. If you are a smoker, we recommend that you stop smoking at least two weeks prior to your surgery If you have had any problems with anesthetics in the past, please discuss this with your surgeon so that your anesthesia provider is aware of this prior to your procedure. If you are currently using a CPAP machine for sleep apnea, please bring the machine with you the day of surgery. Frequently asked questions before surgery Q. What can I eat and drink before surgery? A. You may not eat or drink anything for eight hours before surgery with the exception of some (but not all) medications. Caution: Eating too close to your scheduled surgery may require rescheduling of your surgery. Q. What tests do I need before surgery? A. Required tests may include blood work, heart testing (EKG) or x-rays. Your primary care physician should have these ordered during your pre-op visit. All tests need to be done within 30 days of your procedure. Q. Why do I need to have pre-operative testing? A. Test results can play a role in the selection of anesthetic techniques (e.g., regional anesthesia in the setting of anticoagulation therapy) and they help the anesthesio Continue reading >>
Bariatric Surgery As A Treatment For Type 2 Diabetes
Bariatric Surgery as a Treatment for Type 2 Diabetes by Tomasz Rogula, MD, PhD, Stacy Brethauer, MD, Bipan Chand, MD, and Phillip Schauer, MD To view a PDF version of this article, please click here . Almost 25 percent of Americans are affected by obesity, and between 3 and 5 percent of the adult population is severely affected by obesity, meaning they are 100 pounds or more above their ideal body weight. Morbid obesity is associated with the development of multiple life-threatening conditions, such as diabetes, hypertension (high blood pressure) and heart disease. Combating obesity has been approached through dieting, medications, behavioral modification and exercise. The only treatment for morbid obesity proven to be consistently effective in the long-run, however, is bariatric surgery. Obesity is a very important factor in the development of type 2 diabetes. This disease is marked by high levels of sugar (glucose) in the blood and occurs when the body does not respond correctly to insulin, a hormone released by the pancreas. A person with obesity has double the risk of developing diabetes, and a severely person with obesity is at a tenfold increased risk. The risk of developing diabetes also increases with age, family history and obesity localized more in the abdomen (central obesity). Consumption of fatty and high-carbohydrate foods leads not only to obesity, but also to a higher amount of fatty acids in the blood and a buildup of lipids in the liver and skeletal muscles, causing resistance to insulin and consequently diabetes. Diabetes needs to be treated to improve or normalize blood glucose levels, thereby preventing long-term complications like eye and kidney disease and damage to nerves and blood vessels. Normalized blood glucose reduces the risk of death, str Continue reading >>
Can You Stop Diabetes Meds?
When it comes to diabetes there are many success stories, especially among those who know that diet and exercise play a big part in blood sugar control. Medication is also key to getting your numbers into a healthy range. But if you’re like many people who take something daily for diabetes, you probably wonder if you can ever stop. Maybe -- if your blood sugar numbers are good and you’re committed to a healthy lifestyle. The first step is to talk to your doctor. Here’s what you can expect from that chat. Why Do You Want to Stop? First, know that it's OK to ask your doctor if you can stop taking meds once you’ve met the blood sugar goals you've both set, says Robert Gabbay, MD, PhD, chief medical officer of the Joslin Diabetes Center in Boston. And it can be done, he adds. The first step: Tell your doctor why you want to stop. Then he’ll ask you some questions. The doctor’s looking for specific answers, says endocrinologist Gregg Faiman, MD, of University Hospitals Case Medical Center in Cleveland. He wants to know: Is it too hard for you to keep up with taking your medicine? Do the side effects lower you quality of life? Is the medication too expensive? After that, you and your doctor have to agree about how you’re going to keep your blood sugar under control. You wouldn’t be on the drug if you didn’t need it, Faiman says. “Stopping a medication requires an in-depth discussion. You have to commit to keeping your diabetes under control.” Medication Matters If you take the drug metformin, a common treatment for type 2 diabetes, your doctor could lower it in stages as you lose weight and get fitter, Faiman says. You may even be able to stop it -- at least for a while -- if you’re making good lifestyle choices and you keep your blood sugar under cont Continue reading >>
Fasting For Surgery: What If I Have A Low?
I have diabetes and will be getting an operation. I am not supposed to eat or drink after midnight, but after four hours, my blood glucose drops. What can I take to bring it up? Continue reading >>
Perioperative Management Of The Surgical Patient With Diabetes 2015
Perioperative management of the surgical patient with diabetes 2015 Association of Anaesthetists of Great Britain and Ireland 1Joint British Diabetes Societies Inpatient Care Group Author information Article notes Copyright and License information Disclaimer Copyright 2015 The Authors. Anaesthesia published by John Wiley & Sons Ltd on behalf of Association of Anaesthetists of Great Britain and Ireland This is an open access article under the terms of the Creative Commons AttributionNonCommercialNoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is noncommercial and no modifications or adaptations are made. This article has been cited by other articles in PMC. Diabetes affects 1015% of the surgical population and patients with diabetes undergoing surgery have greater complication rates, mortality rates and length of hospital stay. Modern management of the surgical patient with diabetes focuses on: thorough preoperative assessment and optimisation of their diabetes (as defined by a HbA1c <69mmol.mol1); deciding if the patient can be managed by simple manipulation of preexisting treatment during a short starvation period (maximum of one missed meal) rather than use of a variablerate intravenous insulin infusion; and safe use of the latter when it is the only option, for example in emergency patients, patients expected not to return to a normal diet immediately postoperatively, and patients with poorly controlled diabetes. In addition, it is imperative that communication amongst healthcare professionals and between them and the patient is accurate and well informed at all times. Most patients with diabetes have many years of experience of managing their own care. The purpose of this guideline is to prov Continue reading >>
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 >>
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 . The vast majority of di Continue reading >>
Preoperative Guidelines For Medications Prior To Surgery
Preoperative Guidelines for Medications Prior to Surgery Preoperative Guidelines for Medications Prior to Surgery Aka: Preoperative Guidelines for Medications Prior to Surgery, Preoperative Fasting Recommendation, Nothing by Mouth Prior to Surgery Guideline, Perioperative NPO Guidelines, Perioperative Medication Guidelines, Medication Management in the Perioperative Period, Medications to Avoid Prior to Surgery Rule: 2, 4, 6, 8 rule applies to all ages Fruit juice without pulp (e.g. apple juice) Not allowed as clear liquid: Milk, milk products or Alcohol No clear liquids within 2 hours of surgery Includes orange juice, soda, infant formula and milk No fried foods, fatty foods or meats within 8 hours of surgery These foods are associated with Delayed Gastric Emptying III. Protocol: Medications to still take on morning of surgery Anti-reflux medications (e.g. Omeprazole , Ranitidine ) Risk of withdrawal when abruptly stopped perioperatively Oral Contraceptive s (unless stoped for prevention of DVT) Consider Stress Dose Steroid s if on equivalent of >5 mg/day in 6 months prior to surgery IV. Protocol: Medications to not take on morning of surgery Oral diabetes medications are typically held on the day of surgery (see below) Basal Insulin (e.g. Lantus ) is taken at half dose (on night before or AM of surgery) Bolus Insulin (e.g. Lispro ) is held at home while NPO V. Protocol: Medications to avoid in the perioperative period Medications associated with bleeding risk Short-acting agents: Stop 1 day before surgery Mid-acting agents: Stop 3 days before surgery Long-acting agents: Stop 10 days before surgery Cardiology should be consulted before stopping P2Y agents in post-stenting patients Consider continuing Aspirin while holding the second antiplatelet agent Stop at least 7 Continue reading >>
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 >>
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The Risks Of Surgery For Diabetics
Diabetes and Surgery Risks - What Additional Risks Do I Face? In addition to the normal Risks of Surgery , diabetics face additional risks when having a surgical procedure. These risks are heightened if you have had diabetes for an extended period of time, frequently have high blood sugars, or if you are a brittle (have difficulty controlling your glucose level) diabetic. Patients who have already experienced major complications from diabetes, such as neuropathy or requiring an amputation are also at higher risk. Hyperglycemia (high blood glucose) or hypoglycemia (low blood glucose) can be an issue after surgery Electrolyte Imbalance-A condition where electrolyte levels such as sodium or potassium rise or fall significantly, which can cause significant problems with the heart and the bodys fluid levels. How to Improve Your Surgery Results as a Diabetic - Improve Your Risk Factors What Diabetics Can Do to Be a Better Surgical Candidate The better your control of your diabetes, the better your chances of an excellent surgical outcome. Keeping your blood glucose within the parameters your doctor recommends is key. Top-notch nutrition, including high-quality protein, is also essential. Protein is an important component in the healing process and can help contribute to faster wound healing, stronger tissue at the surgical site and an increased ability to withstand the rigors of surgery. If you arent already exercising but you are able, you may want to start an exercise program after checking with your doctor. Making your body stronger is going to help you better tolerate your surgery and recovery. Try not to get overly stressed about your surgery. If you are feeling anxious about your surgery, c oping with surgical fear and anxiety may help. It is important to keep stress t Continue reading >>
General Pre-op For People With Diabetes
Your Care Instructions Just because you have diabetes doesn't mean you can't have surgery if you need it. Surgery is safer now than ever before. But if you have diabetes, you may need to take extra care. Before your surgery, you may need to check your blood sugar more often. Your doctor may have you do this for at least 24 hours before and for 72 hours after your surgery. If you take insulin or other medicine for diabetes, your doctor will give you exact instructions about how to take them. It may not be the same as how you usually take them. Following is what many doctors advise. But each person is different. If you don't get instructions about your medicines, ask your doctor what to do. And make sure to ask about anything you don't understand. If you take metformin, you may need to stop taking it 48 hours before surgery. And you may need to wait another 48 hours to start taking it again. If you take diabetes medicines other than insulin, you may need to stop taking them on the morning of the surgery. If you take short-acting insulin, you may need to stop taking it on the morning of the surgery. If you take long-acting insulin, you may need to take only half of your usual dose on the morning of the surgery. Follow-up care is a key part of your treatment and safety. Be sure to make and go to all appointments, and call your doctor or nurse call line if you are having problems. It's also a good idea to know your test results and keep a list of the medicines you take. What happens before surgery? Preparing for surgery If you take blood thinners, such as warfarin (Coumadin), clopidogrel (Plavix), or aspirin, be sure to talk to your doctor. He or she will tell you if you should stop taking these medicines before your surgery. Make sure that you understand exactly what your d Continue reading >>
Preparing For Surgery When You Have Diabetes
Work with your health care provider to come up with the safest surgery plan for you. Focus more on controlling your diabetes during the days to weeks before surgery. Your provider will do a medical exam and talk to you about your health. Tell your provider about all the medicines you are taking. If you take metformin, talk to your provider about stopping it. Sometimes, it can be stopped 48 hours before and 48 hours after surgery to decrease the risk of a problem called lactic acidosis. If you take other types of diabetes drugs, follow your provider's instructions if you need to stop the drug before surgery. If you take insulin, ask your provider what dose you should take the night before or the day of your surgery. Your provider may have you meet with a dietitian, or give you a specific meal and activity plan to try to make sure your blood sugar is well-controlled for the week prior to your surgery. Some surgeons will cancel or delay surgery if your blood sugar is high when you arrive at the hospital for your surgery. Surgery is riskier if you have diabetes complications. So talk to your provider about your diabetes control and any complications you have from diabetes. Tell your provider about any problems you have with your heart, kidneys, or eyes, or if you have loss of feeling in your feet. The provider may run some tests to check the status of those problems. You may do better with surgery and get better faster if your blood sugar is controlled during surgery. So, before surgery, talk to your provider about your blood sugar target level during the days before your operation. During surgery, insulin is given by the anesthesiologist. You will meet with this doctor before surgery to discuss the plan to control your blood sugar during the operation. You or your nurses s Continue reading >>
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 >>
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 >>
Periop Meds: What Should You Hold?
Home Clinical Periop meds: What should you hold? A periop primer on which drugs to stop or continue Published in the June 2018 issue of Todays Hospitalist WHEN IT COMES to patients perioperative use of chronic medications, Paul Grant, MD, the director of perioperative and consultative medicine at the University of Michigan Medical Center in Ann Arbor, maintains this general rule: Most meds are tolerated just fine, and it actually wouldnt matter in most cases if you continued them or not on the day of surgery. But some medications have known periop benefits (think statins) or could have rebound or withdrawal effects if stopped, including clonidine, benzodiazepines and opioids. There are also medications that patients should avoid taking the morning of surgery, if not days or even weeks ahead. At a discussion of perioperative medications at this years Society of Hospital Medicine annual meeting, Dr. Grant highlighted his recommendations for what to stop, continue or at least think about. While statins lipid-lowering benefits may not take effect for weeks, the drugs other advantagespreventing plaque rupture, reducing inflammation, optimizing endothelial functionhappen within hours of initiating someone on a statin, Dr. Grant explained. Those can help lower patients perioperative cardiovascular risk. Most meds are tolerated just fine, and it actually wouldnt matter in most cases if you continued them or not on the day of surgery. ~ Paul Grant, MD University of Michigan Medical Center Results from the VISION trial , published in the Jan. 7, 2016, European Heart Journal, found an association between preop statin use and a host of better 30-day outcomes, including lower all-cause and cardiovascular mortality. And a study in the February 2017 issue of JAMA Internal Medicine lo Continue reading >>