Diabetes Mellitus Surgical Patient

Diabetes Mellitus
and the Surgical Patient

Dr. Cathy Code
Division of General Internal
Medicine
Objectives:
 Review the effects of surgery on carbohydrate
metabolism and glucose control
 Provide an overview of the preoperative
assessment of the diabetic patient
 Discuss postoperative diabetic management and
associated complications
 Review the recent evidence for “tight” glycemic
control
Diabetes Mellitus
 Common disorder with increasing

incidence
 5% of the North American population
 In general, diabetics are in poorer health
leading to more surgical procedures
 50% chance that a diabetic will require
surgery in their lifetime
Diabetes Mellitus
 Diabetic microvascular and macrovascular
complications lead to an increased need
for surgery
 Surgery to address:
– Renal failure and its treatment
– Cataracts and retinal disease
– Foot ulcer
– PVD
– CAD
Diabetes
Type 1 DM: Type 2 DM:
 No residual B cell  Insulin resistant
activity  Associated with
 Dependent on obesity
exogenous insulin  Treated with diet,
 Do not respond to OHG +/- insulin
OHG  Can develop HONK
 Can become ketotic  Rarely develop DKA
Type 2 Diabetes
 Diet therapy
 Biguanides ex. Metformin
 Sulfonylureas ex. Glyburide
 Thiazolidinediones ex. Avandia, Actos
 Alpha-glucosidase Inhibitors ex. Prandase
 Meglitinides (non sulfonylurea
secretagogues) ex. Gluconorm
Insulin requiring Diabetes
 Insulin Therapy:
– Once daily dosing (qhs, qam)
– BID dosing (ex. 30/70, 20/80)
– BID intermediate insulin with short acting ac

meals (lispro or regular)
– Continuous SC insulin pump

Diabetics and Surgery
 Requires understanding of CHO

metabolism
 Liver plays central role
 Insulin
– Major anabolic hormone
– Most active in “Fed” state
(gycogenesis/lipogenesis)
– Stimulates glucose uptake into fat and muscle
– Promotes protein anabolism
Diabetes and Surgery
 Insulin deficiency or resistance mimicks
the “Fasting” state
– Glycogen/fat/protein are catabolized to

maintain energy production
– Glucagon promotes gluconeogenesis and
glycogenolysis in liver
– Cortisol promotes protein breakdown
– Catecholamines cause lipolysis and
glycogenolysis
 Energy homeostasis maintained at

expense of body stores
 Surgery and anesthesia are major
stresses that influence glucose
homeostasis
 Counter regulatory hormones cause
insulin resistance and hyperglycemia
 General Anesthesia suppresses
endogenous insulin secretion
 Vasoactive substances can exert anti-
insulin effects
 In DM, insulinopenia leads to
hyperglycemia, increased osmolality,
hypovolemia, abnormal electrolytes, and
in extreme DKA or HONK
 Other concerns beyond insulin:
 CAD
 Autonomic neuropathy
 Peripheral neuropathy
 Diabetic nephropathy
 Wound healing
 Infections
Preoperative Assessment
 Historical features
– Cardiac history and current symptoms
– Other medical conditions
– Long term diabetic complications
– Baseline glycemic control
– Hypoglycemic events?
– Current diabetic treatment
– Type of surgery
– Type of anesthetic planned
 Examination
 Lab tests:
– Glucose +/- Hgb A1C
– Renal function
– Electrolytes
 ECG
 Other
 Aim for optimal glycemic control
(depending on urgency of OR)
 Goal of blood sugar < 11.0
 Benefits
– Normal fluid and electrolyte balance
– Reduced insulin resistance
– Improved endogenous Beta cell
responsiveness (T2DM)
– Decreased hepatic gluconeogenesis
– Improved WBC function and wound healing
Preoperative Management
 General goal to avoid marked

hyperglycemia and avoid significant
hypoglycemia
 Procedures should be arranged as
early in the day as possible
Preoperative Management
 T2DM on diet therapy:
– NPO for procedure
– Usually do not require any specific therapy preop
– Supplemental SC short acting insulin (regular or
lispro) if required for BS > 11.0
 T2DM on OHG:
– Last dose of OHG night before OR
– NPO for procedure
– +/- IV glucose pre op
– Supplemental SC short acting insulin (regular or
lispro) if required for BS > 11.0
Preoperative Management –
DM on insulin
 Typically can continue
SC insulin
perioperatively
 Preop evening dose of
insulin decreased to ~
2/3 to prevent am
hypoglycemia
 May require preop IV
glucose or insulin
Preoperative Management –
DM on insulin
 Short, early morning OR, breakfast
only delayed:
– Delay usual morning insulin
– Administer insulin only after OR when and
able to eat
DM on Insulin:
 Morning procedure, breakfast to be
missed, lunch to be eaten:
– Once daily insulin

 2/3 of am insulin (intermediate acting)
– BID insulin
 1/2 of am insulin as intermediate acting
DM on Insulin
 Morning procedure, breakfast and lunch
meals to be missed:
– Once daily insulin

 1/2 of total am insulin as intermediate acting insulin
– BID insulin
 1/3 of total am insulin as intermediate acting insulin
– Insulin Pump
 Continue basal infusion rate
DM on Insulin
 Procedure later in the day:
– Need to avoid metabolic changes of starvation
– Overall give less insulin and IV glucose

infusion
 Once daily insulin
– 1/2 of total am insulin as intermediate acting
 BID insulin
– 1/3 of total am insulin as intermediate acting
 Insulin pump
– Continue basal infusion rate
DM on Insulin
 Long and complex procedures:
– IV insulin infusion
 Safe
 Start the am of OR
 Short ½ life allows for precise glucose
management
– SC insulin
 Marked variability of glucose concentrations
Postoperative Management
 The pre operative DM regimen may be
reinstated once the patient is eating well
 SC sliding scales are often used to bridge
the gap but
– Cause wide fluctuations in glucose control
– Not physiologic
– If used should be individualized
– Should supplement a basal regimen
Postoperative Management -
Insulin
 Restart insulin at modified dose if required

 Supplement with SC sliding scale with
meals
 For patient on IV insulin, continue until
eating well and ensure overlap with SC
insulin
 Never leave T1DM without insulin – risk for
DKA
Postoperative Management - OHG
 Metformin
– Contraindicated in severe renal impairment
– Avoid in conjunction with IV contrast
 Sulfonylureas
– Can induce sig and prolonged hypoglycemia
– Avoid or modify in erratic or poor PO intake
– Deterioration in renal function can increase risk of
hypoglycemia
 Thiazolidinediones
– Associated with fluid retention
– Avoid in advanced CHF
Postoperative Concerns
 TPN/Enteral Feeding
 Glucocorticoids
 Cardiac complications
 Poor Wound Healing
– DM associated with increased frequency of
wound infections
– Collagen formation, phagocytic activity,
chemotaxis and adherence of granulocytes
adversely affected by hyperglycemia
Postoperative Concerns
 Postop infections
– Impaired phagocytosis and Ab response
 Autonomic neuropathy
– HR/BP, may have unpredictable response to surgical
stress
 Peripheral neuropathy
– Higher risk of pressure ulcers, skin necrosis
 Diabetic nephropathy
– Challenging fluid and electrolyte balance
 Diabetic gastroparesis
– May cause severe postop nausea and vomiting
Evidence for “Tight” Glycemic
Control
 Continuous IV infusion to achieve glycemic
control 4.5-6.0 in postop patients that
require ICU, mechanical ventilation (NEJM
2001)
 IV insulin intraop for Cardiac surgery to
achieve blood sugar b/w 5-11.0 (Ann
Thoracic Surg 1999)
 Perioperative glycemic levels b/w 5-11.0 in
most other surgical situations (Consensus,
CDA)
Conclusions
 DM is a common chronic condition with a
significant subset of complications
 A condition requiring an increased number
of surgical procedures
 Perioperative management is complex
 Patients are at risk for increased morbidity
and mortality without adequate preop
optimization and vigilant postop follow up

Diabetes Mellitus Surgical Patient

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Diabetes Mellitus

and the Surgical Patient

 Common disorder with increasing

– BID dosing (ex. 30/70, 20/80)

– BID intermediate insulin with short acting ac

– Continuous SC insulin pump

 Requires understanding of CHO

– Glycogen/fat/protein are catabolized to

 Energy homeostasis maintained at

 General goal to avoid marked

– Once daily insulin

– Once daily insulin

– Overall give less insulin and IV glucose

 Restart insulin at modified dose if required

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