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2.4: Surgery in Diabetic Patients

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Diabetes Mellitus (DM) is the most common metabolic disorder encountered peri– operatively. Diabetes leads to increased surgical morbidity, mortality and length of hospital stay. Perioperative Hyperglycemia is associated with increased risk of infection, medical complications and death and Hypoglycemia is associated with increased risk of death. The following shall be considered:

  • Ideally, the elective patient should have a preoperative glycated haemoglobin <69mmol/mol (8.5%). The ideal perioperative capillary blood glucose (CBG) should be between 6.0–10.0 mmol/ litre for all patients with diabetes. Surgery should be delayed if possible if HBA1C >9% or blood glucose fasting >10 mmol/l of random > 13 mmol/l.
  • Screen for nephropathy, cardiac disease, retinopathy and neuropathy and inform surgical team.
  • Diabetic patients should be first on the operation list
  • Perioperative glycaemic control and early recognition and management of diabetic related complications improve the operative outcome in diabetic patients. (Refer to specific sections in Diabetic chapter 13)
  • If on diet and or oral agent therapy and well controlled and surgery is minor:
    o Omit therapy on morning of surgery.
    o Resume therapy when eating normally.

 

If on insulin adjust depending on the type of surgery and expected fasting period as follows: 

Minor surgery (duration < 3hours)

  • Insulin: in the morning intermediate–acting insulin, 1/2 to 2/3 of total daily dose
    • if blood glucose is above 20 mmol/l, give a small dose short–acting insulin
    • In the evening give intermediate–acting insulin, 1/3 of daily dose.
  • Fluid: glucose 5% intravenously, volume according to age.
  • Blood glucose monitoring: every 1–2 hours values between 10–14 mmol/l

 

Major surgery (duration > 3hours) Involve a general anesthesia and therefore a period of fasting.

  • Insulin and fluid: infusion solution containing 5% glucose and 20 mmol/l potassium chloride (maintenance volume)
  • Insulin infusion 0.05 IU/kg/hour.
  • Blood glucose monitoring: every 1–2 hours; values between 6–14 mmol/l, if < 5 mmol/l reduce infusion rate, continue infusion therapy intraoperatively.
  • Post operatively: give IV 1 Litre of 5–10% dextrose + 20ml KCl + 2/3 of total daily dose of insulin over 8hrs and repeat to maintain infusion therapy until food intake is re–established.

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