Perioperative management of diabetes.
Maintaining glycemic and metabolic control is difficult in diabetic patients who are undergoing surgery. The preoperative evaluation of all patients with diabetes should include careful screening for asymptomatic cardiac or renal disease. Frequent self-monitoring of glucose levels is important in the week before surgery so that insulin regimens can be adjusted as needed. Oral agents and long-acting insulin are usually discontinued before surgery, although the newer long-acting insulin analog glargine may be appropriately administered for basal insulin coverage throughout the surgical period. The usual regimen of sliding scale subcutaneous insulin for perioperative glycemic control may be a less preferable method because it can have unreliable absorption and lead to erratic blood glucose levels. Intravenous insulin infusion offers advantages because of the more predictable absorption rates and ability to rapidly titrate insulin delivery up or down to maintain proper glycemic control. Insulin is typically infused at 1 to 2 U per hour and adjusted according to the results of frequent blood glucose checks. A separate infusion of dextrose prevents hypoglycemia. Potassium is usually added to the dextrose infusion at 10 to 20 mEq per L in patients with normal renal function and normal preoperative serum potassium levels. Frequent monitoring of electrolytes and acid-base status is important during the perioperative period, especially in patients with type 1 diabetes because ketoacidosis can develop at modest levels of hyperglycemia.
Marks
Jennifer B
JB
Department of Medicine, University of Miami School of Medicine, Miami, Florida 33136, USA. jmarks@med.miami.edu
D000556:Ambulatory Surgical Procedures; D001786:Blood Glucose / Q000032:analysis; D003920:Diabetes Mellitus / Q000175:diagnosis / Q000628:therapy*; D003955:Diagnostic Tests, Routine; D004638:Emergency Treatment; D006801:Humans; D007004:Hypoglycemic Agents / Q000627:therapeutic use; D007262:Infusions, Intravenous; D007279:Injections, Subcutaneous; D007328:Insulin / Q000627:therapeutic use; D019990:Perioperative Care / Q000379:methods*; D011300:Preoperative Care / Q000379:methods; D014882:Water-Electrolyte Balance
D001786:Blood Glucose; D007004:Hypoglycemic Agents; D007328:Insulin