Patients on continuous subcutaneous insulin infusion pumps receive only short-acting regular or lispro insulin and are easily converted to an IV insulin infusion during surgery. For very short procedures or those using local anesthesia, it may be feasible to continue using the patient's insulin pump but, as described above, problems with subcutaneous insulin infusion can arise.
In patients with type 2 diabetes in good control who will not be given insulin during a surgical procedure, glucose levels should be measured approximately every two hours, and insulin therapy should be initiated if the glucose level approaches to mg per dL. Glycemic control can easily deteriorate in the otherwise well-controlled patient undergoing surgery because of metabolic stress responses.
Obesity, sepsis, steroid administration, poor preoperative metabolic control, and recent ketoacidosis also increase perioperative insulin requirements. Most authorities recommend that patients with diabetes be given about 5 g of glucose per hour for basal energy requirements and to prevent hypoglycemia, ketosis, and protein breakdown during surgery.
More glucose may be needed if conditions are very stressful. For example, 5 percent dextrose contains 50 g glucose per L in water or 0. For longer procedures, using 10 percent dextrose contains g glucose per L at 50 mL per hour will avoid excessive fluid administration. A 20 or 50 percent dextrose solution can be given through a central line if fluid restriction is critical. If additional fluids are needed e. Potassium levels should be monitored at least before and after surgery, remembering that a normal serum potassium level does not necessarily reflect a normal total body potassium concentration.
A number of factors can influence serum potassium levels during surgery. Insulin and epinephrine stimulate potassium uptake into cells while hyperosmolarity causes translocation of potassium out of cells and into the extracellular space.
Acidosis can result in hyperkalemia related to the exchange of intracellular potassium for extracellular hydrogen ions. In patients with diabetes with normal renal function and normal serum potassium levels, 10 to 20 mEq per L 10 to 20 mmol per L of potassium should be added per liter of dextrose-containing fluid.
More potassium is given if hypokalemia is present. In patients with hyperkalemia, potassium is not given unless the level falls into the normal range. This approach presents several problems. First, such schemes delay providing insulin until hyperglycemia is present and tend to promote swings in glucose control—high and low. It is important to remember that patients with type 1 diabetes have basal insulin requirements that must be met, even during fasting, to maintain metabolic control.
Use of variable rate insulin infusion in the postoperative period affords the same advantages as noted previously during the intraoperative period. Glucose is measured every one to two hours, and the infusion is adjusted according to the algorithm. Serum electrolytes should be measured postoperatively and daily for as long as the insulin infusion continues, which should be until the patient is ready to resume solid-food intake.
When food is given for breakfast or lunch, the patient's usual dose of morning subcutaneous insulin can be given before the meal, and the infusion can be discontinued two hours later. If supper will be the first solid meal, the evening dose of insulin is given in a similar fashion. In patients who were not previously treated with insulin but who demonstrate a need for insulin during this period, a subcutaneous regimen totaling 0.
This total dose is divided into short-acting insulin before each meal or a combination of intermediate insulin twice daily and short-acting insulin before each meal. Glargine may be a useful basal insulin during this period.
Continuing the insulin infusion while patients are on a liquid diet is preferable. First, caloric intake is likely to be low, and hypoglycemia will be a risk if subcutaneous insulin is being absorbed in the presence of limited amounts of food. This can predispose patients to hyperglycemia and hypoglycemia if the subcutaneous insulin absorption does not match the timing of food absorption.
Note that the insulin infusion is discontinued one to two hours after the first subcutaneous dose to prevent a gap in insulin coverage that could lead to loss of metabolic control. Currently, many surgical procedures are performed on an outpatient basis. Anesthesia, pain, and anxiety can still invoke minor stress reactions and metabolic decompensation. But, by definition, the procedures are minor, and local anesthesia is generally used.
Acceptable management of patients with type 1 and type 2 diabetes can be variable-rate IV insulin infusions or subcutaneous insulin strategies. In patients with type 2 diabetes who are taking oral agents, the same management guidelines should be followed as described for elective surgical procedures.
Patients should be given guidelines for postoperative self-monitoring of blood glucose levels that are appropriate to their type of diabetes. In patients taking insulin, glucose monitoring should take place approximately every two hours for several hours, with algorithms for supplemental insulin administration. In patients with type 2 diabetes, monitoring every four hours is usually sufficient, with instructions to call a physician if glucose levels persistently exceed mg per dL When a normal or near-normal dietary regimen is resumed, most patients can also resume their preoperative diabetic management regimen.
Although opinions differ, and little data are available to allow specifying optimal treatment goals or the best approach to perioperative management of diabetes, it is clear that surgical outcomes are improved in patients with diabetes who are maintained in good metabolic control. Physicians must be cognizant of patients' preoperative control, their relative need for insulin, and any factors that may be likely to increase insulin requirements.
When insulin requirements are in doubt, it is better to err on the side of providing rather than withholding insulin. The administration of adequate glucose in conjunction with the judicious use of insulin will prevent hypoglycemia. Diabetic ketoacidosis or hyperosmolar states, which may result from inadequate dosing of insulin, are not so easily managed. The key to success of any perioperative management plan is frequent monitoring of glucose, electrolyte, and fluid levels, and acid-base status.
Prevention of surgical complications as a result of hyperglycemia is possible with meticulous perioperative glucose management. Already a member or subscriber? Log in. Interested in AAFP membership? Learn more. School of Medicine. Marks graduated from the University of Miami School of Medicine. She is board-certified in internal medicine and endocrinology, diabetes, and metabolism.
Address correspondence to Jennifer B. Marks, M. Reprints are not available from the author. The author indicates that she does not have any conflicts of interest. The author has received grant or research support and honoraria from Aventis Pharmaceuticals, Inc. The author has received honoraria from Pharmacia Corp.
She has served as a consultant or on an advisory panel for Bristol-Myers Squibb Co. Synergistic actions among antiinsulin hormones in pathogenesis of stress hyperglycemia in humans. J Clin Endocrinol Metab. Schade DS. Surgery and diabetes. Med Clin North Am. Acute complications of diabetes: diabetic ketoacidosis and hyperosmolar hyperglycemic nonketotic coma.
In: Hurst JW, ed. Medicine for the practicing physician. Stamford, Conn. Perioperative glycemic control and the risk of infectious complications in a cohort of adults with diabetes.
Diabetes Care. Glucose control lowers the risk of wound infections in diabetics after open heart operations. Ann Thorac Surg. Continuous intravenous insulin infusion reduces the incidence of deep sternal wound infection in diabetic patients after cardiac surgical procedures.
Impaired granulocyte adherence. A hormone called insulin helps transport sugar glucose across the cell membrane so the cell has energy to work. If blood sugar goes too high, the person can go into a coma and die.
Some diabetics are required to take insulin to help control their blood sugar. If they do not receive their insulin they can certainly die. This is what a jail nurse in Mississippi is up against now. A guy, who was a diabetic, was arrested and brought to a Mississippi jail.
Seven days later he was dead because a registered nurse, Carmon Brannan, failed to give him insulin. The nurse called his mother and spoke to her about his diabetes, yet she only took his blood sugar one time in seven days.
The nurse is set to go to trial on October 16, About insulin. There are different types of insulin, taken at different times. Insulin taken once or twice a day This is called long-acting, background or basal insulin.
It gives your body the insulin it needs whether you eat or not. Insulin taken with food or drink This is called fast-acting, mealtime or bolus insulin.
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