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  Diabetopaedia.com---Surgery


Surgery can be major or minor, planned or carried out as an emergency. Sugar control is important before one undergoes surgery of any type.

A person with diabetes needs to have pre-operative fitness and simple protocols are to be followed that would be understood by all the staff.

In type 2 diabetes long acting sulphonylureas can be changed to short acting ones some days before surgery. Metformin should be stopped one week prior to surgery.

A person under going major surgery needs to be on parenteral nutrition, usually intravenous. One should ensure he gets 150 g glucose in 24 hours to prevent ketosis.

All patients undergoing major surgery should be given insulin, usually short acting, in multiple doses.

Monitoring sugar with the use of glucose meter during peri-operative period has been successful in management of diabetes during this period. Insulin is given according to the sugar value with help of sliding scales.

Instructions for Management of Diabetes for a Patient undergoing Surgery

Name:
Referring Surgeon:
Nature of Surgery:
Date and Time of Operation:

Instructions:
1. Pre-operative treatment till the day before surgery:

2. On the day of Surgery:
(a) [ ] No Insulin before Surgery
     [ ] Inj: Plain Insulin/Actrapid MC/ . Units S/c. at
(b) Start one Bottle of 5% Dextrose-Saline/ . Before Surgery at ..

3. After recovery from G.A./After Completion of Surgery (and return to the room) Examine: -
[ ]  Urine Sugar and Acetone (using Keto-Diastix)/
[ ]  Capillary Blood Glucose (using Glucometer or ) at [ ] 6.00 AM, 12 Noon, 6.00 PM, 10.00 PM and record in the table given below (vide - Table).

4. Give injection plain Insulin/Inj. Human Actrapid Insulin or Humalog (Lispro) subcutaneously at the timings noted above according to the sliding scale given below: - (vide - Sliding scale).

5. I. V. Fluids as per Surgeons Instructions: Oral intake .

6. Maintain strict intake-output balance chart.

7. While on IV. Infusions ensure a minimum of 5 to 6 bottles of Dextrose (5%) containing infusion. (i.e. 125 to 150 gms of Glucose per day); when the patient is started on oral feeds - total carbohydrate intake should be maintained at a minimum of 150 gms/day; if oral feeds fall short of this, i.v. Supplementations are essential to avoid Ketonuria/Ketosis.

8. Special Instructions if any:

SLIDING SCALE

Capillary Blood Glucose (Glucometer)
Reading :Mgm/dl
Urine
Insulin(Plain/Human Actrapid) or UMALOG(LISPRO)Dose in Units
Sugar
Acetone
Below - 150                     
151 - 180                     
181 - 210                       
211 - 250                     
251 - 280                     
281 - 300                     
301 - 350                     
351 - HI                     

A Simple and Convenient Chart for Assessing Daily
Blood Glucose Profile, Insulin Requirement

 
Time
24 Hrs
Date
 
6.00A.M
12.00 Noon
6.00P.M
10.00P.M
Remarks
Intake
Output
  
CBG(mg/dl)
                    
Urine
Sugar                     
Acetone                     
Insulin Dose
(Units)
            Total Dose:      
  
CBG(mg/dl)
                    
Urine
Sugar                     
Acetone                     
Insulin Dose
(Units)
            Total Dose:      

Insulin infusion using syringe Driver/Pump

When fluctuations of blood glucose are wide, in critical care conditions (dehydration, water-logging of subcutaneous tissues, etc.) and when parenteral steroids are being given in high doses, insulin should be given continuously through iv route, through the Insulin filled syringe driver at a preset hourly rate (e.g. 1 unit to 10 units per hour), while blood glucose is monitored hourly, 2 hourly or 4 hourly as indicated by the patients condition. The 50 ml syringe is filled with 50 units of either Human Actrapid Insulin or LISPRO (Humalog) Insulin and normal saline upto 50 ml mark, so that 1 ml per hour delivery is equivalent to 1 unit of insulin per hour and so on.



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