PERIOPERATIVE MANAGEMENT

OF THE DIABETIC PATIENT

Supriyanto Kartodarsono
Divisi Endokrinologi dan Metabolik
RSUD Dr Moewardi/Fak Kedokteran UNS
SURAKARTA
OBJECTIVE

• Effect of surgery : overview physiology on carbohydrate metabolism

and glucose control
• Preoperative assesment , Diabetic complication and consider
management of the diabetic patient
• Perioperative stress response to anaesthesia and surgery
• Perioperative management and methode for achiving glycamic control;
How about oral anti diabetic or insulin?
• Perioperative management of patient with diabetes undergoing
emergerncy/elective surgery
• Anaesthetic agent and technique in the diabetic patient; What is the
problem?
• Post operative diabetic management and associated complications
INTRODUCTION

• Patients with diabetes have higher incidence of morbidity

and mortality.
• Poor peri-operative glycaemic control increases the risk of
adverse outcomes.
• Treatment of post-operative hyperglycaemia reduces the
risk of adverse outcomes.
Magnitude of the Problem……

•30%-50% of patients with diabetes

will require some surgery within
their lifetime.

12% of the general population without

diabetes
Thirty-day mortality and in-hospital complication rates in patients with and
without diabetes: blood infection (combined bacteriemia and sepsis);
urinary tract infection (UTI), acute myocardial infarction (AMI), and ARF

Frisch et al Diabetes Care 2010 Aug; 33(8): 1783-1788

Regulatory Hormones a Background

Hypoglycaemic Proglycaemic
• Insulin • Glucagon
• Glucagon-Like Peptide-1 • Catecholamines
• Growth Hormone
• Glucocorticoids
• Somatostatin
Proglycaemic hormones
• Glucagon àKetogenic
• Catecholamine àKetogenic
• Glucocorticoid àKetogenic

•Increase in stress !!!

Therefore, perioperative BS levels
difficult to predict!!!
Blood sugar > 200mg/dl

Renal treshold for glucosuria

Decreased WBC function

Chemotaxsis
Phagocytosis

Decreased for wound healing

Preoperative Considerations,
The threatening Trio

1. Silent Myocardial Ischemia

2. Renal Dysfunction (Elevated

Creatinine)

3. Peripheral/Autonomic neuropathy
Effect of surgery :
Overview physiology on carbohydrate
metabolism and glucose control
DIABETES MELITUS

• Diabetes is a metabolic disorder resulting from

insulin deficiency or insulin resistance
• Associated with acute and long term systemic
problems
• Diagnosed by a random plasma glucose > 200mg/dl
and a fasting glucose> 140 mg/dl (PERKENI)
• The two most common forms of diabetes are Insulin
Dependent Diabetes Mellitus (Type 1) and Non
Insulin Dependant Diabetes Mellitus (Type 2)
• Patients with diabetes have higher incidence of
morbidity and mortality.
• q Poor peri-operative glycaemic control increases
the risk of adverse outcomes.
• q Treatment of post-operative hyperglycaemia
reduces the risk of adverse outcomes.
Type 1 Diabetes Mellitus

• Polygenic disorder thought to be of auto immune

aetiology
• Results in destruction of β cells in the Islets of Langerhans
in the Pancreas, with subsequent insulin deficiency
• Young onset
• 0.4% prevalence
• Exogenous insulin is required to maintain plasma glucose
levels to within physiological levels
Type 2 Diabetes Mellitus

• Hyperglycaemia resulting from reduced insulin

secretion and peripheral insulin resistance
• Some genetic concordance
• Older onset, associated with central obesity
• Depending on severity, may be controlled with:
• diet and exercise to lose weight
• oral hypoglycaemics
• insulin
Diabetes

Type 1 DM: Type 2 DM:

• No residual B cell activity • Insulin resistant
• Dependent on exogenous • Associated with obesity
insulin • Treated with diet, OHG +/-
• Do not respond to OHG insulin
• Can become ketotic • Can develop HONK
• Rarely develop DKA
Type 2 Diabetes

• Biguanides ex. Metformin

• Sulfonylureas ex. Glibenclamide
• Thiazolidinediones ex. Pioglitazone (Actos)
• Alpha-glucosidase Inhibitors ex. Acarbose
• Diet therapy
• Meglitinides (non sulfonylurea secretagogues) ex.
Novonorm
 Insulin therapy in Diabetes
• Insulin Therapy:
• Once daily dosing (long acting/basal insulin)

• BID dosing (ex. Mix 30/70, 25/75, 50/50)

• BID intermediate insulin with short acting ac meals (rapid or

regular)
• Basal-bolus insulin (long acting + rapid/short acting)

• Continuous SC insulin pump

Diabetics and Surgery

• Requires understanding of CHO metabolism

• Liver plays central role
• Insulin
• Major anabolic hormone
• Most active in “Fed” state
(glycogenesis/lipogenesis)
• Stimulates glucose uptake into fat and muscle
• Promotes protein anabolism
Diabetics and Surgery

• Surgery is a form of physical trauma

• It results in catabolism, increased metabolic rate, increased
fat and protein breakdown, glucose intolerance and
starvation.
• In a diabetic patient, the pre existing metabolic
disturbances are exacerbated by surgery
• The type of diabetes, amount of insulin dose, diet or oral
hypoglycaemic agents must be considered as this will
change the overall management plan
• The risk of significant end-organ damage increases with the
duration of diabetes, although the quality of glucose
control is more important than the absolute time
Diabetics and Surgery
• Insulin deficiency or resistance mimicks the
“Fasting” state

• Glycogen/fat/protein are catabolized to maintain

energy production
• Glucagon promotes gluconeogenesis and
glycogenolysis in liver
• Cortisol promotes protein breakdown
• Catecholamines cause lipolysis and glycogenolysis
Diabetics and Surgery

• Energy homeostasis maintained at expense of

body stores
• Surgery and anesthesia are major stresses that
influence glucose homeostasis
• Counter regulatory hormones cause insulin
resistance and hyperglycemia
Diabetics and Surgery

• General Anesthesia suppresses endogenous insulin

secretion
• Vasoactive substances can exert anti-insulin effects
• In DM, insulinopenia leads to hyperglycemia,
increased osmolality, hypovolemia, abnormal
electrolytes, and in extreme DKA or HONK
§ Altered consciousness in perioperative period may
mask the symptoms and signs of hypoglycemia

§ Circulatory disturbance associated with anesthesia

and surgery may interfere with absorption
ofsubcutaneous in sulin à So it is ideal to administer
iv insulin

§ Hyperglycemia is associated with increased risk of

complications such as wound infection and poor
neurological outcomes in susceptible
Neuroendocrine stress response to surgery

• Increased plasma cortisol levels

• Insulin resistance
• Increased hepatic breakdown of glycogen
• Increased gluconeogenesis
• Impaired pancreatic insulin secretion
• Increased fat and protein catabolism
• Potential for hyperglycaemia and ketosis
Diabetics and Surgery

• Other concerns beyond insulin:

Ø CAD
Ø Autonomic neuropathy
Ø Peripheral neuropathy
Ø Diabetic nephropathy
Ø Wound healing
Ø Infections
Goals of perioperative diabetic management

Avoidance of hypoglycemia
Avoidance of marked hyperglycemia
Maintenance of fluid/electrolyte balance
Prevention of ketoacidosis/hyperosmolar
Return to stable glycemic control as so on possible
Adverse events associated with hyper and hypoglycaemia

Hyperglycaemia Hypoglycaemia
• Immune system inhibition and • Impaired autonomic function
increased
• Altered blood flow and
• surgical site infection composition
• Impaired wound healing • White blood cell activation
• Increased perioperative
myocardial infarction • Vasoconstriction
• Worsened neurologic outcomes • Release of inflammatory
mediators and cytokines
• Increased duration of ventilator
dependence • QT prolongation, with a
• Increased risk of perioperative propensity to fatal arrhythmias
death • Increased mortality
Terima Kasih