Management of Anesthesia

Diabetes Mellitus
 AIM
• Avoid hypoglycaemia which can cause
irreversible cerebral damage.
• Avoid severe hyperglycaemia resulting in osmotic
diuresis and severe dehydration (>14 mmol/litre).
• Avoid large swings in glucose, i.e. maintain blood
glucose in the range 6–10 mmol/litre
• Supply cells with insulin so that intracellular
glucose starvation does not occur, preventing
ketoacidosis
• Prevent hypokalaemia, hypomagnesaemia, and
hypophosphataemia.
 Preoperative assessment
• CVS : the diabetic is prone to HTN, IHD, cerebrovascular disease,
MI and cardiomyopathy. Autonomic neuropathy can lead to
tachy- or bradycardia and postural hypotension. Diabetics have
three times the incidence of ischaemic heart disease, and this
may be ‘silent’.
• Autonomic neuropathy (present in 50%) increases the risk of
unstable BP, MI, arrhythmias, gastric reflux, and hypothermia
during surgery.
• Renal: 40% of diabetics develop microalbuminuria, which is
associated with HTN, IHD, and retinopathy. This may be reduced
by treatment with ACE inhibitors.
• Respiratory: diabetics are prone chest infections, especially in
obese and smokers.
• Airway: thickening of soft tissues (glycosylation) occurs,
especially in ligaments around joints-the ‘limited joint mobility
syndrome’. If the neck and mouth opening is affected there may
be difficulty in intubation.
• Gastrointestinal: 50% have delayed gastric emptying
and are prone to reflux.
• Eyes: cataracts are common, especially in the elderly
diabetic.
• Immunity: Diabetics are prone to infections.
• Miscellaneous: diabetes may be caused or worsened
by treatment with corticosteroids, thiazide diuretics,
and the contraceptive pill. Thyroid disease, obesity,
pregnancy, and stress can also affect diabetic control.
• High blood glucose levels are frequently found on
admission to hospital, presumably stress related, and
may settle spontaneously.
• It is not necessary to admit diabetics 2 days before
surgery, unless there are major problems with diabetic
control.
 Investigations
• Blood sugar, Measure blood sugar
preoperatively.
• Test urine for ketones and sugar,
• A glycosylated haemoglobin (HbsAc) >9%
suggests inadequate control of the blood
glucose(normal 3.8–6.4%).
• All diabetic patients should obtain ECG, ECHO
if cardiac problems present.
• Blood urea, s. creatinin, s.electrlytes to be
done
 Preoperative management
• Place first on operating list.
• Evaluate for possible cardiac and renal diseases,
control of hypertension, manage with insuline
and glucose during starvation.
• Stop OHA 24 – 48 hrs before surgery Metformin
and glibenclamide precipitate lactic acidosis.
• Chlorpropamide should ideally be stopped 3 days
before surgery because of its long action. This is
often not possible and should not pose a major
problem if frequent blood glucose monitoring is
undertaken
 Management of insulin- preoperative
• 2/3rd of usual bedtime dose of insulin should be given
the night before surgery and half the usual HPN dose
on the day of surgery. Regular insulin should be
withheld on the morning of surgery.
• A 5% dextrose with 0.45% NS (D51/2NS) iv infusion @
100ml/Hr should be started pre-op
• Insulin Pump : Overnight rate should be decreased by
30%. At basal rates on the day of surgery (0.3U x Wt )
iv or S/c. Pt can be given Glargine ( long acting) and
Pump discontinued in 60-90 mts.
• Pt on Glargine, lispro and aspart : 2/3rd of glargine and
entire lispro or aspart on the night before and stop all
insulin on the day of surgery.
• For major surgery should be delayed ( 4-6Hrs)
if serum glucose is > 270mg/dl for rapid
control with insulin.
• All elective Surgery should be postponed if BS
is > 400mg/dl until sugars are controlled.
 Emergency surgery
• Postponed if high sugar levels if possible for 4- 6 hrs for
control.
• DKA – Treat with Normal saline ( Rehyration) 1l/hr for first 2
hours and 0.4% NS @ 250-500ml/hr. Total fluid deficit is 50 –
100ml/kg.
• An insulin bolus of 0.1 U/kg followed by an infusion of 0.1
U/kg per hour. Serum glucose is monitored hourly. Decrease
dose rate by 50% when serum HCO3 rises above 16mEq.
• electrolytes are monitored every 2 hours. Potassium,
magnesium, and phosphate deficits are replaced when urine
production is documented.
• Potassium: if serum K= ______mEq/l, give_____mEq over
next hour <3 40
3-4 30
4-5 20
5-6 10
<6 0
• Phosphate : if serum PO4 is < 1.0 mg/dl, give
7.7mg/kg over 4 hrs.
• When serum glucose decreases to less than 250
mg/dL, intravenous fluids should include
dextrose. Insulin is continued until acidosis
resolves. Sodium bicarbonate is not routinely
given and is reserved for cases where the pH is
less than 7.10.
• HHS – Treat with normal saline and similar doses
of insulin compared to patients with DKA. These
patients are at significant risk of developing of
cerebral edema and therefore correction of
serum glucose and osmolarity should proceed
gradually over a 12- to 24-hour period.
 Intraoperative management
• Goals to minimize hyperglycemia ( RBS – 120 to 180
mg/dl)
• RBS > 180mg/dl should be treated with Insulin/glucose
regime.
• Check RBS hourly and ketones 4th hourly.
• RL should be avoided – Lactate converts to glucose.
• Rapid sequence induction if gastric stasis suspected.
• Regional techniques are better – chart all pre-existing
nerve damage.
• Autonomic dysfunction may exacrbate the
hypotension effect of SA & EA.
 Intra-operative hypoglycemia
• RBS <60mg/dl should be treated ( caused by fasting, recent
alcohol consumption, liver failure, septicaemia,
sulfonylureas, biguanides, thiazolidinediones, ACE
inhibitors, MAO inhibitors, and nonselective β-blockers).
• Signs and symptoms : tavhycardia, light-headedness,
sweatingand pallor may progress to confusion,restlessness,
incomprehensible speech, double vision, convulsions and
coma. All this is made worse by hypotension and hypoxia.
• Treatment : stop all insulin infusion.
if patient conscious - 25ml of D50% if not available
nasogastric and oral sugars 15-20g.
if unconscious – 50ml of D50% , iv glucose ( 0.5g/kg) –or
glucagon 1mg im/iv/sc.
Recheck BG after 20mts repeat 2minutes of D50 iv if <60mg/dl.
Restart insulin infusion if >70mg/dl for 2 checks.
 IV insuline/dextrose infusion regime
• Start iv 5% dextrose at 120ml/hr or 10% dextrose
at 60ml/hr ( D51/2NS or D 4.5% and 0.18% NS)
• If serum K+ < 4.5 mmol/l add 10mmol Kcl to
500ml bag of dextrose.
• Intravenous insulin according to sliding scale as
shown in table.
• Always infuse insulin in the same line where
dextrose is going, discard first few ml of insulin
containing solution as it may react and get
absorbed by plastic tubing.
 Intravenous insulin sliding scale
Blood glucose (mmol/L) Insulin infusion rate (u/hr) Insulin infusion rate if
blood glucose not
maintained <10
mmol/litre (unit/h)

<3 Stop review after 30mts Stop review after 30mts

3- 4 0.5 0.5

4.1–9 1 2

9.1–13 2 3

13.1–17 3 4

17.1–28 4 6

>28 6 (check infusion running and8 (check infusion running

call doctor) and call doctor)
 Inpatient Insulin Algorithm
ALGORITHM ALGORITHM ALGORITHM
• Goal BG: ________mg/dL   ALGORITHM 1 2 3 4
• Standard Drip: Regular BG Units/hr Units/hr Units/hr Units/hr
insulin 100 units/100 mL
0.9% NaCl via infusion < 60 = Hypoglycemia (See below for treatment)
device    < 70 Off Off Off Off
Initiating the infusion   
• Bolus dose: Regular insulin 70–109 0.2 0.5 1 1.5
0.1 unit/kg = ______units    110–119 0.5 1 2 3
• Algorithm 1: Start here for 120–149 1 1.5 3 -5
most patients.   
• Algorithm 2: Start here if 150–179 1.5 2 4 7
w/p CABG, s/p solid organ 180–209 2 3 5 9
transplant or islet cell
transplant, receiving 210–239 2 4 6 12
glucocorticoids, 240–269 3 5 8 16
vasopressors or diabetics
receiving > 80 units/day of 270–299 3 6 10 20
insulin as an outpatient 300–329 4 7 12 24
330–359 4 8 14 28
> 360 6 12 16  
• Moving from Algorithm to Algorithm
• Moving up: An algorithm failure is defined as BG outside
the goal range for 2 hours (see above goal), and the level
does not change by at least 60 mg/dL within 1 hour.
• Moving down: When BG is < 70 mg/dL for two checks OR if
BG decreases by > 100 mg/dL in an hour. Tube feeds or
TPN: Decrease infusion by 50% if nutrition (tube feeds or
TPN) is discontinued or significantly reduced. Reinstitute
hourly BG checks every 4 hours.
• Patient Monitoring Check capillary BG every hour until it is
within goal range for 4 hours, then decrease to every 2
hours for 4 hours, and if it remains at goal, may decrease
to every 4 hours.
• Treatment of Hypoglycemia (BG < 60 mg/dL)   - treat as
discussed earlier
• Intravenous Fluids Most patients will need 5–10 g of
glucose per hour (D5W or D5 ½ NS at 100–200 mL/hr or
equivalent.
Glucose potassium insulin regime ( GKI or alberti)
• 500ml of 10% dextrose or 5% dextrose + 5 to 20
units actrapid + 10mmol Kcl @ 100l/hr ( provides
insulin 2-3U/hr, potassium 2mmol/hr,glucose
10g/hr)
Blood Soluble Blood KCl (mmol)
glucose insulin potassium to be added
(mmol/litre) (units) to be (mmol/litre) to each 500
added to ml bag
each 500 ml
bag
<4 5 <3 20
4–6 10 3–5 10
6.1–10 15 >5 None
10.1–20 20    
>20 Review If potassium level not
available, add 10 mmol
KCl to each bag
 Post operative care
• Tight glucose control ( 80 – 110mg/dl) – good
neutrophil & macrophage function, beneficial
changes to mucosal/skin barriers, enhanced
erythropoiesis, reduced cholestasis, improved
respiratory function and decreased axonal
degeneration.
• Stop insulin/glucose regime and calculate
total units given in last 24hrs and divide it by
4 or 3 equal doses and give as s/c doses.
 Treatment
• The cornerstones of therapy for type 2 diabetes
are diet with weight loss, exercise therapy, and
the oral antidiabetic agents.
• Low-calorie diets (800–1500 kcal) and very low
calorie diets (<800 kcal) with limits on cholesterol
raising fats and added sugars are used to reduce
body fat and decrease insulin resistance and to
normalize plasma glucose, lipids, and
lipoproteins.
• Oral Antidiabetic Agents.
• Insulin.
 Insulin
Insulins Onset Peak Duration
Short Acting  
Human regular 30 min 2–4 hr 5–8 hr
Lispro (Humalog) 10–15 min 1–2 hr 3–6 hr
Aspart (Novolog) 10–15 min 1–2 hr 3–6 hr
Intermediate  BASAL insulins - used twice daily
Human NPH 1–2 hr 6–10 hr 10–20 hr
Lente 1–2 hr 6–10 hr 10–20 hr
Lispro protamine
Aspart protamine
Long Acting  administered once daily
Ultralente 4–6 hr 8–20 hr 24–48 hr
Glargine (Lantus) 1–2 hr Peakless ∼ 24 hr
• Insulin is necessary to manage all type 1 diabetics and many
type 2 diabetics Conventional insulin therapy uses twice-
daily injections. Intensive insulin therapy uses three or more
daily injections or a continuous infusion.
• Conventional insulin therapy usually requires twice-daily
injections of combinations of intermediate-acting and
short-/rapid-acting insulins
• Humulin 70/30 insulin (70% NPH, 30% regular) given 30
minutes before breakfast and 30 minutes before dinner.
• Novolog 70/30 (70% insulin aspart protamine plus 30%
insulin aspart) given 5 to 15 minutes before breakfast &
dinner.
• Humalog 75/25 (75% insulin lispro protamine plus 25%
insulin lispro) ) given 5 to 15 minutes before breakfast &
dinner.
• Twice-daily separate injections of NPH insulin and regular
insulin or NPH insulin and rapid-acting insulin (lispro, aspart)
are another conventional method of administration.
 3 or 4 injection regime
• Intensive insulin therapy uses three or four daily
injections or a continuous infusion with more
frequent glucose monitoring.
• Three daily injections includes NPH plus short-
acting (regular) or rapid-acting (lispro, aspart)
insulin before breakfast, short-acting or rapid-
acting insulin before dinner, and NPH insulin at
bedtime.
• Four daily injections can include a single injection
of NPH, lente, or insulin glargine (Lantus) at
bedtime plus short-acting or rapid-acting insulin
before breakfast, lunch, and dinner.
Three daily injections
Four daily injections
Four daily injections
 Subcutaneous infusion insulin pump
• A subcutaneous infusion pump uses regular or rapid-
acting insulin with a usual range of 0.5 to 2.0 units per
hour.
• A typical total daily basal dose of insulin equals weight
(kg) × 0.3, with the hourly rate obtained by dividing by 24.
• Basal rates vary during a 24-hour period with lower rates
required at bedtime, higher rates between 3 and 9 AM
and intermediate rates during the day.
• Premeal boluses may also be used, and insulin rates must
be adjusted for exercise. Ideal glycemic goals for type 1
diabetics include the following: before meals, 70 to 120
mg/dL; after meals, less than 150 mg/dL; at bedtime, 100
to 130 mg/dL; and at 3:00 AM more than 70 mg/dL.
Subcutaneous infusion insulin pump
• For many type 2 diabetics, early and aggressive initiation
of insulin therapy has demonstrated beneficial effects.
• Unlike oral agents, insulin has no upper dose limit and
can be adjusted over time to achieve near-normal
glucose levels. Many type 2 diabetics require 0.6 to 1.0
U/kg per day. The amount of insulin needed is not
related to the degree of hyperglycemia but to body
adiposity and other factors of insulin resistance. In most
studies, obese type 2 diabetics require significant daily
doses (100–200 units) to achieve near-normal glycemia.
• Type 2 diabetics who benefit most from insulin therapy
are those who demonstrate catabolism with ketonuria,
persistently elevated glucose levels despite oral therapy,
severe hypertriglyceridemia, uncontrolled weight loss or
severe dehydration with hyperglycemia, or the desire to
maintain near-normal glycemia or induce remission.