It is well recognized, by both patients themselves and their usual advisors, that the treatment of diabetes in hospitalized diabetic patients is often suboptimal. A lack of knowledge of current treatment strategies and lack of familiarity with newer insulins, pen devices and newer hypoglycemic agents by ward staff contributes to substandard care, but can be overcome by the development, distribution and promotion of good treatment protocols, devised by the diabetic team to cover common situations. Many hospitals have now created in-patient diabetic specialist nurses to facilitate this with back-up from the diabetologist to help with more difficult or unusual cases. This is all the more important as many patients undergoing surgery will have diabetes and the metabolic stress of surgical procedures may lead to adverse outcomes if not properly managed. Diabetic patients undergoing surgery are at special risk of hyperglycemia and ketosis, hypo-glycemia, perioperative complications such as wound infection, and iatrogenic problems of blood glucose control.
Factors to consider in the management of diabetic patients are the severity of surgical trauma and its duration, the pre-existing diabetes treatment and the extent of the patient's endogenous insulin reserves. Patients with type 1 diabetes and, for practical purposes, those with type 2 diabetes treated with insulin, are assumed to have no endogenous insulin and hence will require to be covered during surgery with exogenous insulin. Other patients will only require insulin therapy for major surgical procedures.
Protocols for the management of diabetes during surgery need to be simple, practicable, easily understood and, above all, safe. Avoidance of the pursuit of normoglycemia should be advised and it is perfectly acceptable to recommend a target range for blood glucose of around 6-10 mmol/l (108-180 mg/dl). Glucose levels much above this should be avoided as they may interfere with the wound healing process or be associated with increased postoperative infection rates.
Preoperative assessment is most important in diabetic patients undergoing surgery and close liaison between the anesthetist, surgeon and diabetes team is highly desirable, if not vital, in most cases. In general terms, although not always easy to achieve, all patients undergoing surgery who have diabetes should be operated on in the morning. The following treatment principles apply for type 2 patients not on insulin and for insulin-treated patients.
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Diabetes is a disease that affects the way your body uses food. Normally, your body converts sugars, starches and other foods into a form of sugar called glucose. Your body uses glucose for fuel. The cells receive the glucose through the bloodstream. They then use insulin a hormone made by the pancreas to absorb the glucose, convert it into energy, and either use it or store it for later use. Learn more...