Diabetes_mellitus Pre Op

8/4/2019 Diabetes_mellitus Pre Op

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Diabetes and Surgery

The prospect of surgery can make anyonefeel worried and fearful. However, careful

planning, especially for people with diabetes,can help make the operation as safe aspossible and recovery period less stressful.


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Pre- Op To Do List


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1. General Assessment:

It is important to check for the presence of cardiac, renal and

neurological sequelae of diabetes as the presence of these maycomplicate the peri-operative management and increase patient risk.

Please take this opportunity to ensure that patients have had theireyes screened for retinopathy within the last year (either retinal photoor attendance at an Ophthalmology Clinic). If eye screening has notbeen done, please contact the Retinal Screening team directly (tel.01382 740068 or ext. 40068) to arrange an appointment.

Please also ensure that no other diabetes-related problems need to beattended to. If further advice is required, please contact the Diabetesteam.

2. Assessment of Glycaemic Control:

HbA1c is an indicator of recent control i.e. over the previous threemonths. If the HbA1c is above 9 %, control is poor and the Diabetesteam should be involved. If above 12 %, consideration should be givento improving control before elective surgery is undertaken.


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3. Careful Peri-operative Control of Blood Glucose:

The benefit of intensive glucose management in the acute setting isbeing increasingly recognised. The following are intended asguidelines because individual patients and individual circumstancesmay vary.

4. Meet with your primary care doctor or endocrinologist.

5. Talk to your anesthesiologist.

6. Schedule your surgery for the early morning.

7. Talk to your doctor in advance about how you will manage your diabetesimmediately after your operation

8. Get a temporary disabled parking permit, if necessary

9. Fill any new prescriptions before your surgery.

10.Find out how long you will need to recover


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Minor Operations (Body surface or endoscopic procedures)

Omit oral hypoglycaemic therapy on the day of operation and avoid glucose

infusions Check finger prick blood glucose on the morning of the operation and regularly

thereafter as clinical circumstances dictate

The management of these patients is easier if they are operated on early in themorning. For afternoon cases, patients taking oral hypoglycaemic drugs shouldomit these in the early am and have clear fluids only thereafter.

There is no need to stop Metformin any sooner than on the day of surgery Oral medication should be restarted as normally prescribed with the first

meal. The only exception to this is for patients taking Metformin

NB be aware of the potential association between Metformin and lacticacidosis. This is more likely if there is renal impairment present and soMetformin should not be restarted post operatively unless the renal function is

known to be satisfactory Metformin should not be used if eGFR


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Management of patients on insulin (type 1 and type 2)

Pre operatively

All patients on insulin should be adequately controlled pre-operatively and theyshould ideally be stabilised over 48 hours

For patients using twice daily insulin, this may be possible with their usualregime but it may involve switching them to a multiple injection regimen. Forfurther information on multiple injection regimens, see Appendix 3. If in doubtcontact the Diabetes team for advice

For people with type 1 diabetes on multiple daily insulin regimens, it is advisableto continue their usual daily long acting analogue insulin (Lantus or Levemir).

This will reduce the risk of diabetic ketoacidosis if IV insulin is interrupted, and itwill facilitate a smooth transition to subcutaneous insulin at a suitable mealtimepost operatively

Remember that some patients with type 2 diabetes may be treated with

both insulin and Metformin see guidance above regarding monitoring ofrenal function post-operatively before re-starting Metformin

On the day prior to operation, check random venous blood glucose and ureaand electrolytes


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On the morning of the operation Check the blood glucose and commence an

intravenous infusion of glucose and insulin use aGKI infusion unless specifically requested to do

otherwise by the anaesthetist Ensure that the patient does not receive any

subcutaneous rapid acting or pre-mixed insulinon the day of surgery. The last dose of either typeof insulin should have been given on the previousevening

Continue to check the blood glucose hourly, pre,intra and post-operatively


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Post- Op Concerns


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Post-operatively

Change to subcutaneous insulin post-operatively when eatingnormally

It is important to continue the IV insulin infusion for 60minutes after the first subcutaneous insulin injection hasbeen given

If the patient has been previously poorly controlled (HbA1c >9%)please refer to the Diabetes team for further advice beforedischarge


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Hyperglycemia or hypoglycemia: High

or low glucose levels can cause post-operative complications, with highglucose levels topping the list. High

levels increase the likelihood andseverity of other complications. It isimportant to have glucose levels in good

control prior to surgery.
http://diabetes.about.com/od/glossaryofterms/g/hyperglycemia.htmhttp://diabetes.about.com/od/glossaryofterms/g/hypoglycemia.htmhttp://diabetes.about.com/od/glossaryofterms/g/hypoglycemia.htmhttp://diabetes.about.com/od/glossaryofterms/g/hyperglycemia.htm


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Dehydration: The patient may have highurinary output if diabetes is under poorcontrol with increased risk of osmotic

diuresis. This can increase risk for othercomplications
http://adam.about.com/encyclopedia/infectiousdiseases/Osmotic-diuresis.htmhttp://adam.about.com/encyclopedia/infectiousdiseases/Osmotic-diuresis.htm


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Hyperglycemic hyperosmolar syndrome(HHS): This is a situation where thepatient has high glucose levels,

dehydration, and decreasedconsciousness. It is of great concernfollowing certain surgical proceduressuch as cardiac bypass surgery where it

is associated with 42% mortality.
http://adam.about.com/encyclopedia/infectiousdiseases/Diabetic-hyperglycemic-hyperosmolar-coma.htmhttp://adam.about.com/encyclopedia/infectiousdiseases/Diabetic-hyperglycemic-hyperosmolar-coma.htmhttp://adam.about.com/encyclopedia/infectiousdiseases/Diabetic-hyperglycemic-hyperosmolar-coma.htmhttp://adam.about.com/encyclopedia/infectiousdiseases/Diabetic-hyperglycemic-hyperosmolar-coma.htm


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Diabetic ketoacidosis (DKA): Surgery and/orother complications can increase levels ofstress hormones, making insulin lesseffective. If insulin cannot help the body burn

glucose for energy, the body will burn fatinstead. Toxic acid byproducts called ketonesbuild up in the blood and can become life-threatening. Dehydration can accompany and

sometimes cause DKA.
http://diabetes.about.com/od/glossaryofterms/g/ketoacidosis.htmhttp://diabetes.about.com/od/glossaryofterms/g/ketoacidosis.htm


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Impaired wound healing: People withdiabetes are more likely to have poorcirculation, nerve damage, weakened

immune systems, and skin problems.These can slow wound healing andincrease risk for infection
http://surgery.about.com/od/aftersurgery/ss/IncisionCare.htmhttp://surgery.about.com/od/aftersurgery/ss/IncisionCare.htm


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Infection: The most common type ofinfection is incision infection. Risk isincreased in people with diabetes due to

slower healing time. It is important totake all medications as directed andfollow incision care instructions
http://diabetes.about.com/lw/Health-Medicine/Conditions-and-diseases/Common-Infections-in-Diabetes.htmhttp://diabetes.about.com/lw/Health-Medicine/Conditions-and-diseases/Common-Infections-in-Diabetes.htm


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Sepsis: A specific type of whole-bodypost-operative infection due to bacteriain the blood stream. It is severe and

hard to control. Common originationsites after surgery are incisions,intravenous sites, drains, and skin

ulcers
http://surgery.about.com/od/glossaryofsurgicalterms/g/Sepsis.htmhttp://surgery.about.com/od/glossaryofsurgicalterms/g/Sepsis.htm


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Endothelial dysfunction: High glucoselevels increase risk of inflammation orinjury to the lining of blood vessels.

Among other things, endothelial cellsare associated with the transit of whiteblood cells, blood clotting, bloodpressure, inflammation, and

cardiovascular disease
http://diabetes.about.com/gi/o.htm?zi=1/XJ&zTi=1&sdn=diabetes&cdn=health&tm=2993&f=00&su=p284.9.336.ip_p736.9.336.ip_&tt=2&bt=0&bts=1&zu=http%3A//www.uptodate.com/patients/content/topic.do%3FtopicKey%3D%7EjOKKLZJ_q6http://diabetes.about.com/gi/o.htm?zi=1/XJ&zTi=1&sdn=diabetes&cdn=health&tm=2993&f=00&su=p284.9.336.ip_p736.9.336.ip_&tt=2&bt=0&bts=1&zu=http%3A//www.uptodate.com/patients/content/topic.do%3FtopicKey%3D%7EjOKKLZJ_q6


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Ischemia: Lack of blood supply to a partof the body such as the heart, brain,skin or bowel leading to tissue death inthe affected area. People with diabetes

are at higher risk, particularly if theyhave out-of-control glucose levels.Gastrointestinal upset and dehydration

increases risk
http://www.merriam-webster.com/dictionary/ischemiahttp://www.merriam-webster.com/dictionary/ischemia


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Electrolyte imbalance: Nausea, vomitingand dehydration can be caused bystress, medications and anesthesiaresulting in imbalanced blood salts. This

can increase risk for for heartarrhythmias and renal failure. The risk iscompounded in diabetics who arealready at higher risk for coronary and

renal problems
http://adam.about.com/encyclopedia/infectiousdiseases/Fluid-imbalance.htmhttp://adam.about.com/encyclopedia/infectiousdiseases/Fluid-imbalance.htm


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Renal failure: Diabetes is the mostcommon single cause of renal failure.Risk during or after surgery can be

increased by causes such as electrolyteimbalance, dehydration, medicationreactions, abnormal blood pressure,

sepsis and trauma
http://adam.about.com/encyclopedia/infectiousdiseases/Acute-kidney-failure.htmhttp://adam.about.com/encyclopedia/infectiousdiseases/Acute-kidney-failure.htm


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Heart arrhythmias: Risk increases withuncontrolled diabetes, heart disease,certain medications, hypertension,

obesity, and electrolyte imbalance
http://adam.about.com/encyclopedia/infectiousdiseases/Arrhythmias.htmhttp://adam.about.com/encyclopedia/infectiousdiseases/Arrhythmias.htm


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Management of patients on insulin undergoing day case surgery

Aim for

first on list

For those on a multiple injection regimen, continue the usual basal

(long acting) insulin on the evening prior to procedure

For patients on twice daily insulin, continue the usual evening

insulin prior to the procedure

Fast from midnight and omit the morning insulin

Check a finger prick blood glucose before and after the procedure

Resume the usual insulin and diet after the procedure.If a BD

insulin regimen is restarted at lunchtime it is recommended that half

of the normal

breakfast

insulin dose should be prescribed with

lunch after procedure

The above applies if rapid recovery is expected i.e. the patient is

expected to be eating within 2 hours of the procedure


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Ethical And Clinical Issues


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Children as human subjects in

research


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Research involving children raises

significant questions, and families mayneed guidance in considering the risksand benefits of participation.


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In some research studies, results are

provided to the patient. However,results are not disclosed to the patient'sphysician unless the patient chooses todisclose them.

.


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The degree of risk to the child, the directbenefit to the child, and the direct

benefit to other children.


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The nature of the

health problem understudy. The moreserious the problem forchildren, the greaterthe claim that researchcould be justified. Thisis particularly truewhen researchprovides the only

means to identifyhealth care strategiesto address importanthealth problems ofchildren


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The process forsoliciting theassent of children

and thepermission ofparents and

guardians.


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ComplimentaryAlternative Therapy

The National Center for Complementary and AlternativeMedicine (NCCAM), part of the National Institutes of Health(NIH), defines complementary and alternative medicine (CAM)as a group of diverse medical and health care systems,practices, and products that are not generally considered to be

part of conventional medicine. Complementary medicine isused with conventional medicine, whereas alternative medicineis used instead of conventional medicine.
http://www.nccam.nih.gov/http://www.nccam.nih.gov/


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Acupuncture

Acupuncture is a procedure in which a practitionerinserts needles into designated points on the skin.

acupuncture triggers the release of the body's naturalpainkillers and has been shown to offer relief from

chronic pain. Beause of the painkilling nature of acupuncture , it

can be safely used to treat people with neuropathy,the painful nerve damage of diabetes.

Acupuncture was administered once daily for 30days.


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The main acupuncture points used were

quchi(LI-11), sanyinjiao(SP-6),

zusanli(ST-36),

and yishu(special diabetes point located at1.5 cunlateral to the lower border of thespinous process of the 8th thoracic vertebra).

Supplemental points include yuji(LU-10),

guanyuan(CV-4)

baihui(GV-20).


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Biofeedback

Biofeedback is a technique that helps a person become moreaware of and learn to deal with the body's response to pain. Thisalternative therapy emphasizes relaxation and stress-reductiontechniques.

Guided imagery

Guided imagery is a relaxation technique that some

professionals who use biofeedback do. With guidedimagery, a person thinks of peaceful mental images,such as ocean waves. A person may also include the

images of controlling or curing a chronic disease,such as diabetes. People using this technique believetheir condition can be eased with these positiveimages.


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Chromium

The benefit of added chromium for diabetes has been studied anddebated for several years. Several studies report that chromiumsupplementation may improve diabetes control. Chromium is needed tomake glucose tolerance factor, which helps insulin improve its action.Because of insufficient information on the use of chromium to treatdiabetes, no recommendations for supplementation yet exist.

is an essential trace mineralthat is, the body requires smallamounts of it to function properly. Some people with diabetes takechromium in an effort to improve their blood glucose control. Chromiumis found in many foods, but usually only in small amounts; relativelygood sources include meat, whole grain products, and some fruits,vegetables, and spices. In supplement form (capsules and tablets), it is

sold as chromium picolinate, chromium chloride, and chromiumnicotinate.


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Magnesium

Although the relationship between magnesium and diabetes hasbeen studied for decades, it is not yet fully understood. Studiessuggest that a deficiency in magnesium may worsen bloodglucose control in type 2 diabetes. Scientists believe that adeficiency of magnesium interrupts insulin secretion in thepancreas and increases insulin resistance in the body's tissues.

Evidence suggests that a deficiency of magnesium maycontribute to certain diabetes complications. A recent analysisshowed that people with higher dietary intakes of magnesium(through consumption of whole grains, nuts, and green leafyvegetables) had a decreased risk of type 2 diabetes.


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Vanadium

Vanadium is a compound found in tiny amounts in plants andanimals. Early studies showed that vanadium normalized bloodglucose levels in animals with type 1 and type 2 diabetes. Arecent study found that when people with diabetes were givenvanadium, they developed a modest increase in insulin

sensitivity and were able to decrease their insulin requirements.Currently researchers want to understand how vanadium worksin the body, discover potential side effects, and establish safedosages.


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Ginseng

Several types of plants are referred to as ginseng but moststudies of ginseng and diabetes have used American ginseng.Those studies have shown some glucose-lowering effects infasting and post-prandial (after meal) blood glucose levels aswell as in A1C levels (average blood glucose levels over a 3-

month period). However, larger and more long-term studies areneeded before general recommendations for use of ginseng canbe made. Researchers also have determined that the amount ofglucose-lowering compound in ginseng plants varies widely.


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Alpha-lipoic acid (ALA, also known as lipoic acid or thiocticacid) is an antioxidanta substance that protects against cell

damage. ALA is found in certain foods, such as liver, spinach,broccoli, and potatoes. Some people with type 2 diabetes takeALA supplements in the hope of lowering blood glucose levelsby improving the body's ability to use insulin; others use ALA toprevent or treat diabetic neuropathy (a nerve disorder).

Supplements are marketed as tablets or capsules. ALA has been researched for its effect on insulin sensitivity,

glucose metabolism, and diabetic neuropathy. Some studieshave found benefits, but more research is needed. (There aresome studies, reported from outside the United States, of ALA

delivered intravenously; however, this research is outside thescope of this fact sheet.)

Because ALA might lower blood sugar too much, people withdiabetes who take it must monitor their blood sugar levels verycarefully.


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Omega-3 fatty acids are polyunsaturated fatty acids that come

from foods such as fish, fish oil, vegetable oil (primarily canolaand soybean), walnuts, and wheat germ.

Omega-3 supplements are available as capsules or oils (suchas fish oil).

Omega-3s are important in a number of bodily functions,

including the movement of calcium and other substances in andout of cells, the relaxation and contraction of muscles, bloodclotting, digestion, fertility, cell division, and growth.

In addition, omega-3s are thought to protect against heartdisease, reduce inflammation, and lower triglyceride levels.


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Omega-3 fatty acids have been researched for their effect oncontrolling glucose and reducing heart disease risk in people with type

2 diabetes.

Studies show that omega-3 fatty acids lower triglycerides, but do notaffect blood glucose control, total cholesterol, or HDL (good)cholesterol in people with diabetes.

In some studies, omega-3 fatty acids also raised LDL (bad) cholesterol.

Additional research, particularly long-term studies that look specificallyat heart disease in people with diabetes, is needed.

Omega-3s appear to be safe for most adults at low-to-moderate doses.

Safety questions have been raised about fish oil supplements, becausesome species of fish can be contaminated by substances such asmercury, pesticides, or PCBs. I

n high doses, fish oil can interact with certain medications, includingblood thinners and drugs used for high blood pressure.


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Polyphenolsantioxidants found in tea and dark chocolate,

among other dietary sourcesare being studied for possibleeffects on vascular health (including blood pressure) and on thebody's ability to use insulin.

Laboratory studies suggest that EGCG, a polyphenol found ingreen tea, may protect against cardiovascular disease and have

a beneficial effect on insulin activity and glucose control.However, a few small clinical trials studying EGCG and greentea in people with diabetes have not shown such effects.

No adverse effects of EGCG or green tea were discussed inthese studies. Green tea is safe for most adults when used in

moderate amounts. However, green tea contains caffeine, whichcan cause, in some people, insomnia, anxiety, or irritability,among other effects. Green tea also has small amounts ofvitamin K, which can make anticoagulant drugs, such aswarfarin, less effective

If You Have Diabetes and Are Thinking About Using a Dietary Supplement
http://nccam.nih.gov/health/greentea/http://nccam.nih.gov/health/greentea/


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If You Have Diabetes and Are Thinking About Using a Dietary Supplement

Tell your health care providers about any complementary andalternative practices you use. Give them a full picture of what you do tomanage your health. Medicines for diabetes and other health conditions

may need to be adjusted if a person is also using a dietary supplement.

Women who are pregnant or nursing, or people who are thinking ofusing supplements to treat a child, should consult their health careprovider before using any dietary supplement.

Do not replace scientifically proven treatments for diabetes with CAM

treatments that are unproven. The consequences of not following one'sprescribed medical regimen for diabetes can be very serious.

Be aware that the label on a dietary supplement bottle may notaccurately reflect what is inside. For example, some tests of dietarysupplements have found that the contents did not match the dose onthe label, and some herbal supplements have been found to be

contaminated.

Di S l


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Dietary Supplements Preliminary research has explored the use of garlic for lowering

blood glucose levels, but findings have not been consistent.

Studies of the effects of magnesium supplementation on bloodglucose control have had mixed results, although researchershave found that eating a diet high in magnesium may lower therisk of diabetes.

There is not enough evidence to evaluate the effectiveness of

coenzyme Q10 supplementation as a CAM therapy fordiabetes; studies of its ability to affect glucose control have hadconflicting findings.

Some people with diabetes may also try botanicals such asprickly pear cactus, gurmar, Coccinia indica, aloe vera,

fenugreek, and bitter melon to control their glucose levels.However, there is limited research on the effectiveness of thesebotanicals for diabetes.

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