Principles of management:
• Surgery constitutes a major stress
• Insulin needs increase with surgery
• Avoid ketosis
• Avoid hypoglycaemia
High blood glucose concentration matters little over short periods, except in the critically ill. The programme for control should be agreed between anaesthetist and physician whenever diabetic patients must undergo general anaesthesia or modify their diets. There are many different techniques that can give satisfactory results.
TYPE I DIABETES (IDDM)
Elective major surgery
• Admit to hospital the day before surgery
• Arrange operation for morning
• Evening before surgery: give patient's usual insulin
• Day of operation: omit morning s.c. dose; set up i.v. infusion: glucose 5-10% + KC120 mmol/1, infuse at 100 ml/h; insulin 20 units may be added to 1 litre of infúsate or infused by pump at a basal rate of 2-3 units /h and adjusted according to a sliding scale.
• Modify regimen during and after surgery according to monitoring; insulin doses should be adjusted according to similar scale as in Table 35.2
• Stop i.v. infusion one hour after first postsurgical s.c. insulin
• Insulin requirements may be high, 10-15 units /h, in cases of serious infection, corticosteroid use, obesity, liver disease.
For example, simple dental extractions (for multiple extractions or when there is infection the patient should be admitted to hospital). A suitable postoperative diet of appropriate calorie and carbo hydrate content must be arranged. Plan the operation for between 12 noon and 5 pm (17.00 h). Omit the usual dose of long-acting insulin on the morning of the operation and substitute soluble insulin, one-quarter of the usual total daily dose, before a light breakfast 6h preceding the operation. Arrange a light evening meal after the operation and soluble insulin, 10-20 units s.c., according to the blood glucose. Return to the normal routine the next day.
When a surgical emergency is complicated by diabetic ketosis, an attempt should be made to control the ketosis before the operation. Management during the operation will be similar to that for major surgery except that more insulin will be needed.
In other cases small doses of soluble insulin are given 2-4-hourly (where pumps are not available), keeping the blood glucose between 5 and 8 mmol/1.
TYPE 2 DIABETES (NIDDM)
Elective and emergency surgery, and minor surgery if NIDDM is poorly controlled: use the same regimen as for IDDM.
Minor surgery: If NIDDM is well controlled, omit the oral hypoglycaemic agent on the morning of surgery. If the surgery is more than trivial, monitor blood glucose carefully, and use soluble insulin s.c. or by infusion if blood glucose rises. If vomiting is likely, use insulin.
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