Perioperative Management Of The Type Diabetic Major Surgery

Type 2 diabetics unable to increase endogenous insulin secretion may behave metabolically in the perioperative period similar to the classic patient with type 1 diabetes (1,14,44). Insulin therapy and frequent blood glucose monitoring are required to minimize the risk for ketoacidosis and hypoglycemia (16,17). A variable-rate insulin infusion/fixed-rate glucose infusion method provides the greatest flexibility, safety, and degree of glycemic control.

Surgery should be scheduled as early in the morning as possible. A solution of glucose should be started around 7:00 am and infused at a rate of 5 to 10 g/h. Patients that normally take NPH and regular insulin before breakfast may take one-half to two-thirds of their usual dose (of each type of insulin) on the morning of surgery. Regular insulin should be withheld if the fasting glucose measurement detects hypoglycemia. The dose should be increased if fasting glucose exceeds 200 mg/dL. Alternatively, patients may be given NPH or Glargine insulin at bedtime the night before surgery. Upon awakening, the patient can receive one-half to two-thirds of their usual morning dose of NPH insulin (with little or no regular insulin) or their full dose of Glargine. The NPH insulin dose from the evening before will peak around 6:00 to 9:00 am and the morning dose will attenuate post-operative hyperglycemia (16,17,44). When early morning surgery is not feasible, the morning dose of subcutaneous insulin should be withheld and intravenous infusions of insulin and glucose started around 7:00 am and titrated to hourly glucose measurements. The infusions can be discontinued once the patient is able to tolerate food, or restarted if the patient experiences prolonged nausea and emesis (15). Following satisfactory return of GI function, subcutaneous regular insulin can be carefully titrated according to meals and the clinical situation (44).

Patients with type 2 diabetes previously managed by diet, exercise, and oral hypoglycemic agents should have sufficient endogenous insulin production to avoid ketosis and excessive hyperglycemia. Subcutaneous insulin regimens may be considered when the clinician anticipates a brief period of fasting in a patient with well-controlled BG levels. Short-acting sulfonylurea agents are typically held the day of surgery while the longer-acting agent Chlorpropamide is held for 2 to 3 days prior to surgery. The biguanide Metformin is typically held prior to surgery in patients at risk for renal or hepatic dysfunction due to the uncommon occurrence of lactic acidosis. Glucose levels must be monitored frequently if oral hypoglycemia agents are continued up until the day of surgery (14,44,61,62). Post-operative type 2 diabetic patients that require < 24 units of insulin per day can be converted to oral agents once tolerating food. A significant number of diabetic patients previously on oral agents will require insulin following discharge from the hospital.

Patients using an external insulin pump with rapid-acting insulin (CSII) should continue basal rate therapy until the time of surgery. The pump should be removed prior to surgery, followed immediately by an intravenous infusion of regular insulin. Insulin should never be withheld in patients with suspected type 1 diabetes because ketoacidosis can develop while the patient is waiting for surgery.

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