“According to the American Diabetes Association it is
estimated that 12-25% of hospitalized adult patients have diabetes mellitus.
With the increasing prevalence of diabetic patients undergoing surgery, and the
increased risk of complications associated with DM, appropriate perioperative
assessment and management are imperative.” http://emedicine.medscape.com
"An estimated 25% of diabetic patients will require surgery.
Mortality rates in diabetic patients have been estimated to be up to 5 times
greater than in nondiabetic patients, often related to the end-organ damage
caused by the disease.” http://emedicine.medscape.com)
Tight control of blood glucose has been proven to reduce the
rate of surgical infections.
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Currently, there is not a defined optimal target range
for blood glucose to prevent in surgical patients, it has been suggested that
80-150mg/dl, will reduce the rate of postop surgical infections. Of course, the
ultimate goal in the management of a diabetic patient is to achieve results equal
to those in patients without DM.
Some evidence suggests that at least a quarter of diabetic patients
are unaware of their disease, it may prove beneficial to screen all patients
undergoing surgery. (At the facility I work at we currently check every patient
who walks through our doors for diabetes. Every patient is screened 3 times via
POC, if they have 1 blood sugar greater than 200mg/dl during the screening nurses initate the hyperglycemia protocols, which entails drawing an HbA1C,
sliding scale coverage for BS greater than 150 until endocrinologist rounds and
accu checks are changed to AC/HS. If they have two blood sugars greater
than 150mg/dl we initiate the same protocol. During our screening of all patients we diagnosis
so many “new” diabetics it is scary, the disease is running rampant and most
people are unaware of their condition.
General Preoperative Management
On day of surgery most patients will be advised not to take
their diabetes medications, this will help reduce the number hypoglycemia
events.
Patients who are on insulin are advice to reduce their
bedtime basal dose the night before the surgery to prevent hypoglycemia while
patient is not eating by mouth. Maintenance insulin maybe continued during
surgery based on the recommendations of the physician.
Metabolic response to Anesthesia and Surgery
Surgery places considerable amount of stress on one’s body causing
an increase in blood sugars
Anesthetic agents can also affect glucose metabolism
resulting in hyperglycemia and possibly ketoacidosis
According the American Diabetes Association patients
undergoing cardiac surgeries should have a blood glucose target of less than
150mg/dl, this will reduce mortality and reduce the risk of sternal wound
infections.
Methods of achieving blood sugar control
“Because of the numerous potential perioperative complications
in diabetic patients, close monitoring is imperative to maintain glycemic control,
while minimizing hypoglycemia.” http://emedicine.medscape.com
After surgery patients who were taking oral agents may be
able to resume their medications. Healthcare personnel need to assess if the
oral medication is appropriate because of potential complications or if IV
insulin is the best choices, as it is easily titratable.
For example, Glyburide can cause hypoglycemia, has prolonged
action, and is difficult to titrate. Metformin has potential risk of lactic
acidosis and must be used cautiously in renal and CHF patients. Actos needs to
be used cautiously in CHF patients and is also difficult to titrate.
Another method for controlling perioperative blood glucose
is through the use of IV insulin. Several insulin protocols are available,
including computer-based systems that will calculate the dosing based on the
blood glucose. At the facility I work at we use such a computer based program
for controlling BS postoperatively.
Discussion Topic: How to prevent SSI?
References:
http://emedicine.medscape.com
American Diabetes Association
