Skip to main content
SpringerLink
Log in

Special Surgical Situations and Diabetes Management: Part 1

  • Chapter
  • First Online:
Towards Optimal Management of Diabetes in Surgery

  • 400 Accesses

Abstract

It is desirable to admit patients who are not controlled optimally with or without being treated by insulin. Admissions 2–3 days prior to stabilize glucose control and optimize insulin doses will help postoperatively a great deal. The attempt should be to reach a fasting blood glucose level between 80 and 120 mg/dL and a bed time level of 100–140 m/dL. It is desirable to switch the patients on long-acting insulin to intermediate-acting insulin as it provides greater flexibility to alter doses for quicker control. Changing to intermediate acting insulin should be done preferably on admission for control or at least a couple of days earlier 1–2 days before elective surgery. In cardiac surgery in particular wide swings of glycemia occur. Hence frequent perioperative blood glucose monitoring followed by action by changing insulin infusion rates or subcutaneous doses or glucose supplementation as the case may be is crucial for better postoperative outcomes.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Log in via an institution
Chapter
USD 29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD 69.99
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD 89.99
Price excludes VAT (USA)
  • Compact, lightweight edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info
Hardcover Book
USD 109.99
Price excludes VAT (USA)
  • Durable hardcover edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

Notes

  1. 1.

    The authors faced this problem in the early 1990s. Till then the syringe pumps had not been a routinely available implement. To reduce the wastage as well as to achieve finer control, we devised the mid drip technique described in detail earlier. See also in Commonly Asked Questions for Alberti regime and its evolution.

  2. 2.

    Rarely one may come across a situation wherein cerebral circulation is severely compromised in the form of unilateral complete block of one carotid artery with or without narrowing of the other. In such situations, carotid endarterectomy will take precedence over CABG since in such a situation under non-pulsatile flow of CPB, massive cerebral infarction is highly likely. As a general rule, carotid Doppler may be a useful preoperative procedure in CABG or high-risk major surgery.

  3. 3.

    Acetazolamide, 250 mg thrice a day, is used in patients with brain edema instead of mannitol, which once the surgery is over is possibly not required to be given at all. Acetazolamide does contribute in a small way to metabolic acidosis but helps in increasing the respiratory drive reducing the hypercapnia-induced CO2. It also has a mild diuretic action.

  4. 4.

    For the pharmacokinetic and pharmacodynamic properties of these insulins, please see the chapter of the same title in this volume. It will help to make a choice among the many available now. The major differences among them are the frequency and severity of hypoglycemia during the night in particular. This consideration minimizes its importance in the situation of steroid-induced hyperglycemia with or without diabetes.

  5. 5.

    One other situation where such or even higher units of insulin are needed is the gestational diabetes or in diabetes with pregnancy since that is also a high insulin resistance state with hyperglycemia which has to be controlled at all costs.

  6. 6.

    In Northeastern India, correcting anemia in patients without nephropathy is also a difficult undertaking. Many native populations have widespread prevalence of hemoglobinopathy with characteristic normochromic microcytic RBCs. No matter what one may try, it is not possible to raise Hb beyond 9 g/dL. Similarly, there is widespread prevalence of congenital polycystic kidneys in these and other populations to a lesser extent which over years lead to end-stage nephropathy. The practice of prescribing PPIs (proton pump inhibitors) is almost universal. PPIs may be contributing to B12 deficiency. The water content of heavy metals, particularly arsenic, is high. Whether it interferes in the process of iron absorption leading to correction of anemia or causes it is not clear.

References

  1. Niles NW, McGrath PD, Malenka D, et al. Survival of patients with diabetes and multivessel coronary artery disease after surgical or percutaneous coronary revascularization: results of a large regional prospective study. Northern New England Cardiovascular Disease Study Group. J Am Coll Cardiol. 2001;37:1008–15.

    Article  CAS  Google Scholar 

  2. Investigators TBARI. Influence of diabetes on 5-year morbidity and mortality in a randomized trial comparing CABG and PTCA in patients with multivessel disease. Circulation. 1997;96:1761–9.

    Article  Google Scholar 

  3. Crock PA, Ley CJ, Martin IK, Alford FP, Best JD. Hormonal and metabolic changes during hypothermic coronary artery bypass surgery in diabetic and non-diabetic subjects. Diabet Med. 1988;5:47–52.

    Article  CAS  Google Scholar 

  4. Devineni R, Mckinzie FN. Surgery for coronary artery disease in patients with diabetes mellitus. Can J Surg. 1985;28:367–70, cited by Subhankar Chowdhury, Sujoy Ghosh SUPPLEMENT OF JAPI JULY 2007 VOL. 55.

    CAS  PubMed  Google Scholar 

  5. Burton D, Nicholson G, Hall G. Endocrine and metabolic response to surgery. Cont Educ Anaesth Crit Care Pain. 2004;4(5):144–7. https://doi.org/10.1093/bjaceaccp/mkh040.

    Article  Google Scholar 

  6. Hirsch IB, McGill JB. Role of insulin management of surgical patients with diabetes mellitus. Diabetes Care. 1990;13:980.

    Article  CAS  Google Scholar 

  7. Baumann H, Gauldie J. The acute phase response. Immunol Today. 1994;15:74–9.

    Article  CAS  Google Scholar 

  8. Desborough JP. The stress response to surgery. Br J Anaesth. 2000;85:109–17.

    Article  CAS  Google Scholar 

  9. Wright PD, Johnston IDA. The effect of surgical operation on growth hormone levels in plasma. Surgery. 1975;77(4):479–86.

    CAS  PubMed  Google Scholar 

  10. Alberti KG, Marshall SM. Diabetes and surgery. In: Alberti KG, Krall LP, editors. Diabetes annual/4. New York, NY: Elsevier; 1988. p. 248–71.

    Google Scholar 

  11. Clutter WE, Rizza RA, Gerich JE, Cryper PE. Regulation of glucose metabolism by sympathochromaffin catecholamines. Diabetes Metab Rev. 1988;4:17–30.

    Article  Google Scholar 

  12. Schricker T, Carvalho G. An ounce of prevention worth a pound of cure. Can J Anesth. 2004;51:948–9.

    Article  Google Scholar 

  13. McAlister FA, Man J, Bistritz L, et al. Diabetes and coronary artery bypass surgery: an examination of perioperative glycemic control and outcomes. Diabetes Care. 2003;26:1518–24.

    Article  Google Scholar 

  14. Simmons D, Morton K, Laughton S, Scott DJ. A comparison of two intravenous insulin regimens among surgical patients with insulin dependent diabetes mellitus. Diabetes Educ. 1994;20:422–7.

    Article  CAS  Google Scholar 

  15. Bolk J, van der Ploeg T, Cornel JH, et al. Impaired glucose metabolism predicts mortality after a myocardial infarction. Int J Cardiol. 2001;79:207–14.

    Article  CAS  Google Scholar 

  16. Lawrie GM, Morris GC, Glaeser DH. Influence of diabetes mellitus on the results of coronary artery bypass surgery. JAMA. 1986;256:1967–71.

    Article  Google Scholar 

  17. Halkos ME, Lattouf OM, Puskas JD, et al. Elevated preoperative hemoglobin A1c level is associated with reduced long-term survival after coronary artery bypass surgery. Ann Thorac Surg. 2008;86:1431–7.

    Article  Google Scholar 

  18. Mangano DT, Layug EL, Wallace A, et al. Effect of atenolol on mortality and cardiovascular morbidity after non cardiac surgery. Multicenter Study of Perioperative Ischemia Research Group. N Engl J Med. 1996;335:1713–20.

    Article  CAS  Google Scholar 

  19. McAlister FA, Amad H, Man J, Tandon P, Bistriz L. Diabetes and coronary bypass surgery. Diabetes Care. 2003;26:1518–24.

    Article  Google Scholar 

  20. Furnary A, Gao G, Grunkeimer GL, et al. Continuous insulin infusion reduces mortality in patients with diabetes undergoing coronary artery bypass grafting. J Thorac Cardiovasc Surg. 2003;125:1007–21.

    Article  CAS  Google Scholar 

  21. Rady MY, Ryan T, Starr NJ. Perioperative determinants of morbidity and mortality in elderly patients undergoing cardiac surgery. Crit Care Med. 1998;26:225–35.

    Article  CAS  Google Scholar 

  22. Haga KK, McClymont KL, Clarke S, et al. The effect of tight glycemic control, during and after cardiac surgery, on patient mortality and morbidity: a systematic review and meta analysis. J Cardiothorac Surg. 2011;6(1):Article 3.

    Article  Google Scholar 

  23. Carvalho G, Moore A, Qizilbash B, et al. Maintenance of normoglycemia during open cardiac surgery. Anesth Analg. 2004;99:319–24.

    Article  CAS  Google Scholar 

  24. Parsonage WA, Hetmanski D, Cowley AJ. Beneficial haemodynamic effects of insulin in chronic heart failure. Heart. 2001;85:508–13.

    Article  CAS  Google Scholar 

  25. Pomposelli J, Baxter J, Babineau T, et al. Early postoperative glucose control predicts nosocomial infection rate in diabetic patients. J Parent Enter Nutr. 1998;22:77–81.

    Article  CAS  Google Scholar 

  26. Measley RE Jr. Chapter 3: Antimicrobial prophylaxis: prevention of postoperative infections. In: Merli GJ, Weitz HH, editors. Medical management of the surgical patient. 3rd ed. Philadelphia, PA: Saunders; 2008, eBook ISBN: 9781437710588, Paperback ISBN: 9781416023852.

    Google Scholar 

  27. Duncan AI, Koch CG, Xu M, et al. Recent metformin ingestion does not increase in-hospital morbidity or mortality after cardiac surgery. Anesth Analg. 2007;104:42–50.

    Article  CAS  Google Scholar 

  28. UK Prospective Diabetes Study (UKPDS) Group. Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). Lancet. 1998;352:837–53.

    Article  Google Scholar 

  29. Jacobi J, Bircher N, Krinsley J, et al. Guidelines for the use of an insulin infusion for the management of hyperglycemia in critically ill patients. Crit Care Med. 2012;40:3251–76.

    Article  Google Scholar 

  30. Ali Z, Prabhakar H. Fluid Management during Neurosurgical Procedures. J Neuroanaesthesiol Crit Care. 2016;3(Suppl S1):35–40.

    Google Scholar 

  31. Glister BC, Vigersky RA. Perioperative management of type 1 diabetes mellitus. Endocrinol Metab Clin N Am. 2003;32:411–36.

    Article  CAS  Google Scholar 

  32. Greenstone MA, Shaw AB. Alternate day corticosteroid causes alternate day hyperglycaemia. Postgrad Med J. 1987;63:761–4.

    Article  CAS  Google Scholar 

  33. Ratner RE, Hirsch IB, Neifing JL, et al. Less hypoglycemia with insulin glargine in intensive insulin therapy for type 1 diabetes. US Study Group of Insulin Glargine in type 1 Diabetes. Diabetes Care. 2000;23:639–43.

    Article  CAS  Google Scholar 

  34. Plantinga LC, Crews DC, Coresh J, et al. Prevalence of chronic kidney disease in US adults with undiagnosed diabetes or prediabetes. Clin J Am Soc Nephrol. 2010;5:673–82.

    Article  Google Scholar 

  35. American Association of Clinical Endocrinologists, AACE Diabetes Resource Center. Management of common comorbidities of diabetes. Jacksonville, FL: American Association of Clinical Endocrinologists, AACE Diabetes Resource Center; 2016. http://outpatient.aace.com/type-2-diabetes/managementof-common-comorbidities-of-diabetes. Accessed June 2016.

    Google Scholar 

  36. Kroon L. Making sense of medications for diabetes [lecture]. San Francisco, CA: University of California, San Francisco, Osher Center for Integrative Medicine; n.d.

    Google Scholar 

  37. Lum CT, Sutherland DER, Goetz FC, et al. Management of the diabetic patient before, during and after surgery with special emphasis on uremic patients and kidney transplant recipients. Minn Med. 1985;68:693–6.

    CAS  PubMed  Google Scholar 

  38. Johnston O, Rose CL, Webster AC, Gill JS. Sirolimus is associated with new-onset diabetes in kidney transplant recipients. J Am Soc Nephrol. 2008;19:1411–8.

    Article  Google Scholar 

  39. Chakkera HA, Mandarino LJ. Calcineurin inhibition and new-onset diabetes mellitus after transplantation. Transplantation. 2013;95(5):647–52.

    Article  CAS  Google Scholar 

  40. Soleimanpour SA, Crutchlow MF, Ferrari AM, et al. Calcineurin signaling regulates human islet beta-cell survival. J Biol Chem. 2010;285:40050–9.

    Article  CAS  Google Scholar 

  41. Tsang CK, Qi H, Liu LF, Zheng XF. Targeting mammalian target of rapamycin (mTOR) for health and diseases. Drug Discov Today. 2007;12:112–24.

    Article  CAS  Google Scholar 

  42. Yang SB, Lee HY, Young DM, et al. Rapamycin induces glucose intolerance in mice by reducing islet mass, insulin content, and insulin sensitivity. J Mol Med (Berl). 2012;90:575–85.

    Article  CAS  Google Scholar 

  43. Mange KC, Joffe MM, Feldman HI. Effect of the use or nonuse of long-term dialysis on the subsequent survival of renal transplants from living donors. N Engl J Med. 2001;344:726–31. https://doi.org/10.1056/NEJM200103083441004.

    Article  CAS  PubMed  Google Scholar 

  44. Becker BN, Rush SH, Dykstra DM, Becker YT, Port FK. Preemptive transplantation for patients with diabetes-related kidney disease. Arch Intern Med. 2006;166:44–8. https://doi.org/10.1001/archinte.166.1.44.

    Article  PubMed  Google Scholar 

  45. Cosio FG, Pesavento TE, Kim S, Osei K, Henry M, Ferguson RM. Patient survival after renal transplantation: IV. Impact of post-transplant diabetes. Kidney Int. 2002;62:1440–6.

    Article  Google Scholar 

  46. Kasiske BL, Snyder JJ, Gilbertson D, Matas AJ. Diabetes mellitus after kidney transplantation in the United States. Am J Transplant. 2003;3:178–85.

    Article  Google Scholar 

  47. Woodward RS, Schnitzler MA, Baty J, et al. Incidence and cost of new onset diabetes mellitus among U.S. wait-listed and transplanted renal allograft recipients. Am J Transplant. 2003;3:590–8.

    Article  Google Scholar 

  48. Fourtounas C. World J Transplant. 2014;4(2):102–10.

    Article  Google Scholar 

  49. Arnouts P, Bolignano D, Nistor I, et al. Glucose-lowering drugs in patients with chronic kidney disease: a narrative review on pharmacokinetic properties. Nephrol Dial Transplant. 2014;29(7):1284–300.

    Article  CAS  Google Scholar 

  50. Suresh KR. Statistics from a tertiary Institute of Vascular Surgery, JIVAS, Bengaluru, India. Bengaluru: JIVAS; 2018.

    Google Scholar 

  51. Crawford F1, Welch K, Andras A, Chappell FM. Ankle brachial index for the diagnosis of lower limb peripheral arterial disease. Cochrane Database Syst Rev. 2016;9:CD010680.

    PubMed  Google Scholar 

  52. Arsenault KA, McDonald J, Devereaux PJ, Thorlund K, Tittley JG, Whitlock RP. The use of transcutaneous oximetry to predict complications of chronic wound healing: a systematic review and meta-analysis. Wound Repair Regen. 2011 Nov;19(6):657–63.

    Article  Google Scholar 

Additional Reading

  • National Guidelines for Management of Diabetic Foot, published by Diabetic Foot society of India, 2017.

    Google Scholar 

  • Preoperative Testing and Medication Management The Ohio State University Wexner Medical Center. 2017.

    Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Private Practice, Pune, Maharashtra, India

    Sanjeev Kelkar

  2. Senior Consultant Anesthesiologist, Central India Institute of Medical Science, Nagpur, Maharashtra, India

    Shubhangi Muley

  3. Consultant, Anesthesioligist, Fortis S L Raheja Hospital, Mumbai, Maharashtra, India

    Prakash Ambardekar

Authors
  1. Sanjeev Kelkar
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Shubhangi Muley
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Prakash Ambardekar
    View author publications

    You can also search for this author in PubMed Google Scholar

Rights and permissions

Reprints and permissions

Copyright information

© 2019 Springer Nature Singapore Pte Ltd.

About this chapter

Check for updates. Verify currency and authenticity via CrossMark

Cite this chapter

Kelkar, S., Muley, S., Ambardekar, P. (2019). Special Surgical Situations and Diabetes Management: Part 1. In: Towards Optimal Management of Diabetes in Surgery. Springer, Singapore. https://doi.org/10.1007/978-981-13-7705-1_7

Download citation

  • DOI: https://doi.org/10.1007/978-981-13-7705-1_7

  • Published:

  • Publisher Name: Springer, Singapore

  • Print ISBN: 978-981-13-7704-4

  • Online ISBN: 978-981-13-7705-1

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics

Search

Navigation