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Post Operative Care For Diabetic Patients

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 >>

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 >>

Pre And Post-operative Needs Of Patients With Diabetes

Pre And Post-operative Needs Of Patients With Diabetes

Pre and post-operative needs of patients with diabetes Paula Holt Lecturer in diabetes care, School of Healthcare, University of Leeds The incidence of diabetes is rising rapidly and individuals with the condition often have complex comorbidities, which may increase the need for surgical procedures such as amputation and cardiac, renal and eye surgery. Patients with diabetes undergoing surgery may have specific needs, particularly in relation to blood glucose control, and healthcare professionals need to be able to assess and manage these individuals to ensure optimum surgical outcomes. This article considers the potential effects of anaesthesia and surgery on blood glucose control. Diabetes-related complications, particularly signs and symptoms, and effects of these complications on patient safety during surgery are discussed. Specific pre and post-operative care of patients with type 1 and type 2 diabetes is described, with reference to nil-by-mouth practices, blood glucose control, and post-operative infection and pain. Nursing Standard. doi: 10.7748/ns2012.08.26.50.50.c9240 Continue reading >>

An 18-year-old Patient With Type 1 Diabetes Undergoing Surgery

An 18-year-old Patient With Type 1 Diabetes Undergoing Surgery

Description of Case An 18-year-old Caucasian male with type 1 diabetes presented to the emergency department complaining of severe left knee pain and swelling after sustaining a knee injury that occurred during a high school football match. Joint effusions were visible and palpable above the left knee, and there was significant loss of smooth motion of the knee, passively performed. Plain X rays showed no signs of fractures. The patient had had type 1 diabetes for six years, and his insulin regimen consisted of insulin glargine, 35 units at 8:00 p.m., and insulin lispro, 23 units at 8:00 a.m. and 16 units at 8:00 p.m. The patient had no apparent complications related to type 1 diabetes. On examination he was alert, his pulse was 76 bpm regular, and his blood pressure was 118/66 mm Hg. Recently, the patient had had frequent episodes of both hyperglycemia and hypoglycemia. However, he had never developed diabetic ketoacidosis (DKA). His recent HbA1c was 9.5%, demonstrating inadequate glycemic control. The patient was referred to an orthopedic surgeon, and arthroscopy was scheduled a few days later. A complex tear of the medial meniscus extending to the articular surfaces was diagnosed. Partial meniscectomy was recommended. (This procedure usually takes about one hour—nonetheless, the preoperative preparation for general anesthesia and the postoperative recovery may add several hours to this time.) When Would You Have This Patient Report to the Hospital? The Day before Surgery or the Morning of Surgery? This patient should be hospitalized no later than the evening before surgery, given his history of frequent episodes of hypo- and hyperglycemia and his poor glycemic control. This should allow for final optimization of glucose control before surgery. Ideally, frequent con Continue reading >>

Post-op Concerns For People With Type 2 Diabetes

Post-op Concerns For People With Type 2 Diabetes

People with Type 2 diabetes have to worry about more than the normal risks and complications after an operation. Risks associated with diabetes and surgery are increased dependent on age, diabetes treatment regimen, level of control, existing complications or illness, malnutrition, length of time with diabetes, and general physical fitness. Post-Op Concerns The physical and mental stress of surgery can cause undesirable changes in hormone levels. These changes lead to increased insulin resistance, lowered insulin secretion, and lessened glucose uptake into cells. These increase the risk for hyperglycemia in a person with diabetes. The following list of concerns illustrates the importance of having glucose levels in control prior to an operation: : High or low glucose levels can cause post-operative complications, with high glucose levels topping the list. High levels increase the likelihood and severity of other complications. It is important to have glucose levels in good control prior to surgery. Dehydration: The patient may have high urinary output if diabetes is under poor control with increased risk of osmotic diuresis. This can increase risk for other complications. Hyperglycemic hyperosmolar syndrome (HHS): This is a situation where the patient has high glucose levels, dehydration, and decreased consciousness. It is of great concern following certain surgical procedures such as cardiac bypass surgery where it is associated with 42% mortality. (DKA): Surgery and/or other complications can increase levels of stress hormones, making insulin less effective. If insulin cannot help the body burn glucose for energy, the body will burn fat instead. Toxic acid byproducts called ketones build up in the blood and can become life-threatening. Dehydration can accompany and so Continue reading >>

Guideline On Peri-operative Glycemic Control For Adult Patient With Diabetic Mellitus: Resource Limited Areas - Sciencedirect

Guideline On Peri-operative Glycemic Control For Adult Patient With Diabetic Mellitus: Resource Limited Areas - Sciencedirect

Guideline on peri-operative glycemic control for adult patient with diabetic mellitus: Resource limited areas Author links open overlay panel Yophtahe WoldegerimaBerhe To improve care provision regarding glucose control in diabetic patients. Intensive glucose control decreased overall post-operative complications. Continuous insulin infusion associated with significant reduction in wound infection. Continuous insulin infusion is more effective in controlling blood glucose. Perioperative glycemic control, intensive insulin therapy, conventional insulin therapy. Poor glucose control/Hyperglycemia is associated with perioperative complications. Optimal evidence-based perioperative blood glucose control in patients undergoing surgical procedures remains controversial. There are different controversial approaches on glycemic control based on variety of evidences. So it is important to design and developed protocol to provide safe perioperative care for diabetic patients that align with our clinical setup. The objective of this guideline was to improve care provision regarding glucose control in diabetic patients during the Perioperative period. PubMed through HINARI, Google Scholars and other search engines were used to find high level evidences that help to draw appropriate conclusions. Comparing conventional and intensive glucose control, even though, intensive approach was found associated with reduced complication rates, recent large scale studies concluded no difference in complication rates, organ failure, and ventilator support requirements. The intensive approach, even found associated with more episodes of hypoglycemia and higher delayed mortality rates. Regarding insulin administration modalities, continuous infusion was found to help stable glycemic control, redu Continue reading >>

Inpatient And Pre/peri-operative Management Of Diabetes

Inpatient And Pre/peri-operative Management Of Diabetes

Inpatient and Pre/Peri-operative Management of Diabetes Inpatient and Pre/Peri-operative Management of Diabetes What every physician needs to know about diabetes Diabetes is a highly prevalent, chronic medical disorder that is present in approximately 25 - 30% of hospitalized patients, and approximately 20 - 25% of those admitted for elective and non-elective surgical procedures. While outpatient attention to glycemic control has been demonstrated to be associated with reduction in risk for diabetes related microvascular and neuropathic complications, short term attention to glycemic control during hospitalization is associated with reductions in morbidity, mortality, hospital length of stay (LOS), and need for readmission. Patients with diabetes have a higher lifetime risk of undergoing a surgical procedure than those without diabetes. Appropriate glycemic management during the peri-operative time period helps to ensure optimal surgical and patient outcomes. Because diabetes is frequently associated with other metabolic disorders that increase the risk for cardiovascular disease, such as obesity, hypertension, and hyperlipidemia (see Chapter on Diabetes and Cardiovascular Disease), careful pre-operative assessment of potential cardiovascular risk factors in addition to glycemic control is indicated. Hyperglycemia, defined as any blood glucose level >140mg/dl, in the absence of a prior history of known diabetes, is associated with adverse outcomes in a variety of inpatient clinical settings. Potential causes of hyperglycemia in hospitalized patients include: Unrecognized or newly diagnosed diabetes: In the United States, approximately 7 million individuals have diabetes and are unaware of it. There are even more patients with pre-diabetes who are at risk of developing Continue reading >>

Glycemic Behavior In 48 Hours Postoperative Period Of Patients With Type 2 Diabetes Mellitus And Non Diabetic Submitted To Bariatric Surgery

Glycemic Behavior In 48 Hours Postoperative Period Of Patients With Type 2 Diabetes Mellitus And Non Diabetic Submitted To Bariatric Surgery

PrintversionISSN 0102-6720On-lineversionISSN 2317-6326 ABCD, arq. bras. cir. dig.vol.28supl.1So Paulo2015 GLYCEMIC BEHAVIOR IN 48 HOURS POSTOPERATIVE PERIOD OF PATIENTS WITH TYPE 2 DIABETES MELLITUS AND NON DIABETIC SUBMITTED TO BARIATRIC SURGERY Although there is no indication for surgery taking only into account the glycemic condition, results have shown that benefits can be obtained in glycemic control with bariatric surgery. : To compare the glycemic behavior among type 2 diabetic and non-diabetic patients within 48 h after bariatric surgery, and clarify whether there is a reduction in blood glucose level in obese patients with diabetes before the loss of weight excess. : Descriptive epidemiological study with prospective cohort design with 31 obese patients undergoing Roux-en-Y gastric bypass and sleeve gastrectomy. The patients were controlled with hemoglucotests in different periods of time: preoperative, postoperative and each 6 h after surgery for 48 h. : Average ambulatory blood glucose in diabetics was 120.72.9 mg/dl vs 91.813.9 mg/dl in the nondiabetic. After 48 h there was decrease in diabetics to 100.017.0 mg/dl (p=0.003), while the non-diabetic group did not change significantly (102.725.4 mg/dl; p=0.097). There were no differences between the surgical techniques. There were no death. : Diabetic patients significantly reduced blood glucose after surgery regardless of the use of exogenous insulin or oral hypoglycemic agents. Key words: Bariatric surgery; Metabolic surgery; Type 2 diabetes mellitus Nowadays, due to the nutritional transition, obesity and type 2 diabetes mellitus (T2DM) have been considered an epidemic disease. OMS data from 1980 through 2008 show that the prevalence of obesity has more than doubled within this period 27 . In the year 2011 Continue reading >>

Diabetes Complicates Postsurgical Recovery, But Study Suggests Method To Identify Those At Risk

Diabetes Complicates Postsurgical Recovery, But Study Suggests Method To Identify Those At Risk

For years, physicians have struggled to predict the postsurgical recovery time of their patients—a variable with unknown causes. Gauging the period of recovery gives patients a sense of how soon they may be up and about, returning to their normal lives and to work. A prolonged recovery time can have multiple consequences, including psychosocial ones for the patient and economic ones for society. For persons with diabetes, recovery from surgery is particularly complicated. Research has shown that insulin resistance could result from surgery, and its intensity could define the recovery period. These patients also face a greater risk of infection and wounds that do not heal, leading to other health problems and higher hospital costs. Patients who suffer these complications risk being readmitted to the hospital, which brings on the added costs. The need to identify which patients face this risk has never been greater, as the Affordable Care Act (ACA) has brought new penalties for hospitals that see too many readmissions within 30 days of discharge. Now, a new study from Stanford University has opened up the potential for predictive gene signatures and the development of a diagnostic test that could foretell clinical recovery.1 Such a test could have enormous value when surgical patients have diabetes, for it could help hospitals stratify and target patients for enhanced care to prevent readmission. Traditional recovery parameters have included metrics such as length of hospital stay, while recent studies have focused on more patient-centered outcomes such as absence of symptoms, ability to perform regular activities, return to work, and quality of life. While there have been attempts to define the process of postoperative recovery, various stakeholders view the matter dif Continue reading >>

Unique Surgical Wound Care Concerns For Diabetics

Unique Surgical Wound Care Concerns For Diabetics

Diabetics have higher risks of wound healing complications following surgery. If you have diabetes, you are well aware of the importance of maintaining control of your blood sugar levels to prevent serious health problems. The same is true when it comes to surgical wound care. When you undergo surgery, because you have diabetes, you are at a much higher risk of having complications or developing a wound infection. Uncontrolled blood sugar levels can cause serious and even life-threatening complications, making safe and effective wound care practices crucial following surgery. Post-Surgery Risks Surgical procedures normally carry with them a risk of wound infection, excessive bleeding, or tissue damage. When you undergo surgery while also dealing with diabetes, your chances of developing complications is significantly higher. Researchers have found that those with high blood sugar levels before or after surgery run a higher risk of having their wounds reopen through dehiscence, which is a common cause of infections. If you experience stress due to your surgery or have difficulty controlling your blood sugar levels, your body can become even more resistant to insulin, produce lower amounts of insulin, and absorb lower amounts of glucose. These issues can become contributing factors to your ability to recover. The biggest concerns associated with surgical wound care for people with diabetes include the following: Wound Healing – Wounds tend to require more time to heal in those with diabetes. This can be due to nerve damage, poor blood circulation, or a compromised immune system. These effects make it harder for post-surgical wounds to heal effectively, so it is imperative you follow your physician’s surgical wound care instructions. Wound Infection – Surgical incisi 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 >>

Postoperative Management Of The Diabetic Patient.

Postoperative Management Of The Diabetic Patient.

Abstract Diabetic patients are at increased risk for adverse outcomes of surgery. These adverse outcomes are related to pre-existing complications of diabetes, especially atherosclerotic disease, nephropathy (and perhaps increased susceptibility to other renal toxins), and peripheral and autonomic neuropathy. Hyperglycemia is associated with likely risks for poorer wound healing, increased susceptibility to infection, and probable loss of administered nutrients through glycosuria. Insulin use has the flexibility of timing and dose in the postoperative management of most diabetic patients. The combinations of intermediate-acting and long-acting insulins and short-acting insulins usually are related to the experience and preferences of the treating physicians and allied health professionals. Intravenous insulin (always R) may be limited to administration in the ICU because of the need for frequent blood glucose monitoring and rapidity of glucose response to intravenous insulin. The use of short-acting insulin analogues has been shown to work well as premeal insulin or for rapidly treating marked hyperglycemia in the outpatient setting. Meal delivery in the hospitalized patient may not be timed as precisely as in the home situation. Nurses may be responsible for many patients. The rapid-acting analogues may be associated with increased risk for hypoglycemia in the hospitalized patient if insulin cannot be given immediately before a meal. These rapid-acting insulin analogues usually are limited to circumstances in which the patient can determine the dose and self-administer just before ingestion of the meal. The long-acting insulin analogues may not afford enough flexibility in many situations in which daily dosages changes are occurring in intermediate-acting and long-acti Continue reading >>

Perioperative Management Of The Diabetic Patient

Perioperative Management Of The Diabetic Patient

Overview 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 surgery. [7, 8, 9] Fortunately, tighter glycemic control has been shown to have a profound effect on reducing the incidence of m 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 >>

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 >>

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