Perioperative management of diabetes Virtually all physicians will inevitably be confronted with diabetic patients requiring anaesthesia and

Surgery. This high-risk group will undergo cardiovascular and ophthalmological procedures at a greater rate than will their nondiabetic peers. They may also require a transplant associated with diabetes, such as a kidney transplant in the setting of renal failure or a pancreas transplant. Furthermore, diabetic complications may require penile prosthesis implantation, ulcer debridement, or limb amputation.
Many of the problems arise because diabetic patients are not able to maintain a balance between insulin and its counterregulatory hormones. Surgery and anesthesia provoke a neuroendocrine stress response, which releases these counterregulatory hormones and causes hyperglycemia and increased catabolism. The magnitude of the response depends on the severity of surgery and on complications such as sepsis, hypotension, hypovolemia, and acidosis. The major risk factors affecting diabetic patients undergoing

surgery include cardiovascular dysfunction, renal insufficiency, joint collagen tissue abnormalities (e.g. cervical joint stiffness) and neuropathies (cardiovascular and GI effects). End organ damage by diabetes may be more important indicator of perioperative outcome than diabetes itself. During the postoperative period, diabetic patients face poor wound healing, increased incidence of acute renal failure, and increased infection rates.

Surgery produces stress response which is modified by anaesthetic agents. For e.g. midazolam infusion blunts hyperglycemia evoked by surgical stress, succinylcholine increases potassium levels. Clonidine decreases the release of ACTH and cortisol, improves perioperative haemodynamics and decreases the requirement for anaesthetics. Dexmedetomide decreases insulinsecretion, volatile agents like halothane, enflurane, isoflurane inhibit insulin response to glucose in reversible and dose dependent manner.Propofol and haloganated agents like halothane, sevoflurane produce greater negative inotropic effects in diabetics. The main concern of the anaesthesiologist in the peri-operative management of diabetic patients has always been the avoidance of harmful hypoglycaemia; made more difficult by the reduced level of consciousness masking its signs and symptoms. Type I diabetic patients need some level of insulin at all times and might be considered candidates for tight control of blood glucose (80-110 mg/dL). Type 2 diabetic patients have endogenous insulin and current data support the concept that they do not benefit from similarly tight control unless they are in an intensive care setting. According to the most recent ACC/AHA guidelines, it is prudent to control glucose levels (< 150 mg/dL) in patients who develop acute hyperglycaemia, or have diabetes and are at risk for acute myocardial infarction and are undergoing vascular or major noncardiac surgery with a planned intensive care unit admission. Tight glycaemic control (< 110 mg/dL) in the peri-operative period is not universally accepted. Furthermore, one can expect frequent (524%) episodes of hypoglycaemia, potential increases in

mortality and the need to monitor glucose levels closely. Maintaining glucose levels to < 180 mg/dL appears to be an appropriate goal. Hyperglycemia has many other adverse effects. It can impair wound healing by hindering collagen production, resulting in decreased tensile strength of surgical wounds. Hyperglycemia can increase infection because glucose levels above 250 mg/dl are thought to impair leukocyte chemotaxis and phagocytosis. Other effects include an increase in plasminogen activator factor inhibitor and abnormal platelet function resulting in abnormal coagulation. Finally, hyperglycemia may exacerbate ischemic brain damage in the elderly Presurgical Evaluation
a physical exam should be performed and a complete diabetic history current level of metabolic control and diabetic complications, including renal function, heart disease, presence of autonomic neuropathy, and any history of DKA or HHNK. pharmacological regimen, dosages, and timing of medication ingestion dietary intake, including carbohydrate content and timing of meals

physical activity level before surgery

labs should include a chemistry panel, complete blood counts, thrombin and prothrombin times, liver function tests, and a pregnancy test for women of childbearing potential routine preoperative chest X-rays. Certainly, patients with known underlying pulmonary disease or risk factors such as smoking should have routine chest X-rays before surgery. elective surgery for diabetic patients should be delayed after a cardiac event, if possible. (EKG) on all patients. There should be a low threshold for stress testing if the resting EKG shows evidence of ischemia or a patients history is suggestive of coronary artery disease cardiac risk indexes Renal function microalbuminuria. If this is positive, order a 24-h urine collection to determine creatinine clearance Hypertension is not a contraindication to surgery if it is well controlled to at least 140/90 mmHg autonomic neuropathy predisposes patients to perioperative hypotension impaired gastric emptying risk for aspiration. In addition, postoperative resumption of oral nutrition may be difficult.