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FOR
DIABETES MELLITUS
LIYA ABRAHAM
    
— Diabetics come for surgeries for common
problems and also for procedures prompted by
long term complications
— They face several challenges due to imbalance
between insulin and its counter regulatory
hormones secreted during stress
Hypo tension , hypovolemia , acidosis, in post op
period face poor wound healing , ARF and
infection
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— HISTORY:
— History specific to diabetes: polyuria,
polydipsia, weight loss weakness
— Known diabetic ± duration since onset
— H/o infections ± skin boils carbuncle, fever
candidiasis , burning micturition,non-
healing foot ulcers etc.
— H/s/o episodes of unconsciousness
— H/o events precipitating DKA like
inadequate insulin ,infection- UTI, RTI ,
GE,SEPSIS
 

— Diabetic retinopathy: h/o diminution or loss
of vision
— Diabetic neuropathy: Mononeuropathy- 3rd
6th or 7th nerve involvement
— Peripheral neuropathy- sensory loss glove
and stocking type


— dizziness, lightheadedness, diminution of vision

on standing , syncope and heat intolerance
— Gastro paresis: anorexia, nausea, vomiting early
satiety or abdominal bloating
— Genitourinary dysfunction: cystopathy which
includes hesitancy decreased voiding frequency
incontinence and recurrent UTI,
— Erectile dysfunction, retrograde ejaculation or
female sexual dysfunction
 
— Drug history: OHA ± name ,dosage and timing of
ingestion
— Insulin ± type dosage and timing details
— Details of all other co morbidities IHD,HTN,CRF
and medications
— Past history: hospitalizations in past any
complications and details
— Family history : of diabetes
— Personal history regarding dietary intake if high
calorie diet - may be on higher dose medication an
dec dose required pos op during fasting also ask
for the extent of daily physical activity as inc dose
requirement when phy activity limited
perioperatively
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— General- nourishment and built
— Vitals : Pulse ± resting tachycardia
_ irregularity
_ changes with deep breathing,
valsalva and sustained hand grip
— Blood pressure- look for orthostatic hypotension
— Urine output
— Temperature ± increased in infections
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— RS : V
V:
specifically look for stiff joints
prayer sign/ palm print sign
IP joint stiffness A cervical joint
stiffness
Look specifically for any signs of resp tract
infections
— CNS: - detailed examn including
- cranial nerves for mononeuropathy
ÿ sensory loss
-muscle wasting
- sup and deep tendon reflexes
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— Urine routine:glucose, albumin, ketone
bodies, microscopy
— Blood glucose levels: FBS, PPBS, HbA1c
— Renal function: BUN, serum creatinine,
serum electrolytes
— CVS ± ECG, lower threshold for stress
testing and ECHO
— Tests for autonomic neuropathy- @

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— NPO for 8 hrs . They should preferably be 1st on
the list to prevent prolonged fasting an
hypoglycemia an if prolonged blood glucose has
to be monitored
— Ranitidine and metoclopramide are given night
before an day of surgery to dec acid secretion and
promote gastric emptying
— FBS, SE and UKB on the morning of surgery
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— Type 2 diabetes on diet control for short elective
procedures no treatment only blood glucose
monitoring
— Patients on OHA s like newer generation
sulfonylureas(ex.glyburide, glipizide) and
thiazolidinediones(ex. Rosiglitazone, pioglitazone)
± OHA withheld on the morning of surgery
— Metformin should be stopped 24 hrs before the
procedure to prevent the possibility of lactic
acidosis if the patients renal function gets
compromised
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— Patients on insulin- minor procedure skip the

morning dose of insulin
— Patients undergoing major surgeries with longer
recovery periods on either OHA s or on long
acting insulin should be discontinued and started
on a regimen of short acting insulin
— All type 2 diabetics uncontrolled or undergoing
major surgeries are managed like insulin
dependent diabetics
 
— Non tight regimen
— At 6am on the day of surgery start 5% D
maintenance rate and ½ the morning dose
of insulin is given subcutaneously
Tight control regimen
— Regimen 1:
— 5%D started @ 50 cc/hr
— ³piggyback´ insulin infusion (50u in 250ml
NS) insulin rate(u/hr) = plasma
glucose(mg/dl)/150
 
— GIK regimen- Alberti and Thomas
— Initial 500ml 10% D +10mmol Kcl+15U
insulin @ 100ml/hr
— Glucose <6.5mmols ± soln with 10 u @
2u/hr
— Glucose between 6.5and 11.1soln with 15u
@ 3u/hr
— Glucose >11.1soln with 20u @4 u /hr

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— Type 1 pt with ketoacidosis or type 2 pt with
hyperosmolar coma requires stabilization before
surgery unless an acute emergency
— Dehydration electrolyte imbalances have to be
adequately corrected
— Ketoacidosis should b allowed to resolve and pt
should be stabilized on GIK regimen if surgery is
not life saving
— In case of pressing surgical conditions like
vascular injury or intra abdominal emergency , the
risks of delay must be weighed against incomplete
metabolic resolution and the surgical stress in
deciding the optimum time for surgery.