DIABETES AND SURGERY

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Slide 1 : DIABETES RELATED TO SURGERY Fiaz Fazili DIABETES RELATED TO SURGERY Fiaz Fazili
Slide 2 : Objectives of our lecture??? Why is Diabetes important To Surgeon? Problems in patient having Diabetes Who should control this? Preoperative workup Peri- operative Management Diabetic Foot-Special emphasis
Slide 3 : DIABETES MELLITUS-AN EVOLVING EPIDEMIC DM is an incurable lifelong disease characterized by persistent hypoglycaemia It is a multisystem disease with wide ranging and devastating complications which end up in severe disability and death
Slide 4 : Diabetes prevalence Diabetes has world wide distribution commonly seen in developed countries Recently gulf countries noticed increase trend Kingdom of Saudi Arabia –common disease Urban population 4.95% Rural population 4.30% One in every five Saudis above age of 30 years is Diabetic (Al Nuain et al –Prevalence of DM in Saudi Arabia –Nat Chron Dis Suvey.
Slide 5 : LET NOT AUTUMN FALL ON u Early TREAT DIABETES EARLY AND REGULARLY
Slide 6 : DIABETES TYPES DIABETES TYPES TYPE I TYPE II Secondary Drug Induced
Slide 7 : DIABETES TYPES-JUVENILE IDDM-juvenile onset DM 20% of all Diabetics Onset in childhood Insulin dependant Prone to Ketosis and acidosis
Slide 8 : DIABETES TYPES -ADULT Non insulin dependant Above 30 yrs –Obese Insulin resistance is common Less prone to ketosis and acidosis.
Slide 9 : DRUG INDUCED Thiazides Corticosteroids
Slide 10 : SECONDARY DIABETES Pancreatic Insufficiency Haemochromatosis Following Pancreatic Surgery
Slide 11 : What Surgeon Should Be Cautious Of; Diabetics are at 50% increased risk of Morbidity and Mortality Cardiovascular complications Poor wound Healing Metabolic complications Infective complications
Slide 12 : Metabolic derangement Hyperglycaemia Acidosis Hyperlipaedaemia
Slide 13 : Problems in Diabetics Macrovascular disease Peripheral arterial disease Coronory arterial disease(silent CAD) Mesentric vascular insufficiency Cerebral vascular insufficiency
Slide 14 : CAUTION MI often with an atypical presentation is the leading cause of perioperative death among Diabetics CAUTION CAUTION
Slide 15 : Chronic complications Neuropathy(autonomic dysfunction) Postop Hypotension Urinary retention Gastro paresis Nephropathy Fluid and Electrolyte imbalance ARF Retinopathy
Slide 16 : INFECTION AND DIABETES Common infections Pyelonephritis Papillary necrosis Perinephric abscess Unusual infections Necrotizing fascitits Gingivitis &pyorrhea Malignant O.E Fungal infections
Slide 17 : Diabetes-Infection PNL function deranged Chemo taxis is less Phagocytic activity is deranged Intracellular bactericidal activity is reduced
Slide 18 : PRE OP ASSESSMENT History Complications H/o heart disease Drug history Symptoms of infection
Slide 19 : Pre op Asessment-Phy- Exam Opthalmoscopy Blood pressure Circulation Neurological exam Status of feet
Slide 20 : Pre op assessment-lab work Blood glucose, serum Na, k, NaHco3 Renal function Cardiac evaluation-EKG,RIS, CORONORY ANGIO
Slide 21 : Pre op Elective Cases Admit 2days before surgery Blood sugar should be monitored Oral hypoglycemic agent should (esp chlorpropamide stopped 36hrs before OR) Operation should be scheduled at morning hours Iv feeding with dextrose Started
Slide 22 : Pts-On Oral Hypoglycemic Discontinue Medication evening prior to Schedule OR-(chlorpropamide 2-3 days before) Pts may require IV glucose when fasting or Insulin if blood sugar >250 mgm /dl pre op
Slide 23 : DIET Controlled -NIDDM Can be maintained safely without food or glucose infusion prior to surgery
Slide 24 : IDDM-NIDDM Pts on Insulin These Pts require insulin and glucose pre operatively .Dosing should reflect the type of Diabetes IDDM Preoperative regimen Anticipated degree of surgical stress
Slide 25 : Diabetics –Poorly controlled Pts with DKA who require Emergency OR, Pre op every attempt should be made to Correct Acidosis Electrolyte imbalance Hypokalaemia Volume depletion Control BS with I V Insulin
Slide 26 : EMERGENCY SURGERY IN IDDM Acute surgical Emergencies cause DKA and may mimic Acute Abdomen Don’t rush for OR Initial blood /urine exam-chem.,ABG,ketone Start Iv saline rapidly Need bolus doses of insulin and Kcl Once blood sugar I <14mmol insulin Sub cut
Slide 27 : Surgery in NIDD Minor Surgery- Diet or OHG or Insulin withhold all agents and check Bs Major surgery Diet is observed D/C OHG replace with Iv Insulin
Slide 28 : Post Operative Management Diet controlled NIDDM After minor OR Need Iv Glucose and Insulin Major OR.. Iv Dextrose while fasting, check BS every 4-6hrs, and sub cut Insulin coverage
Slide 29 : Post Op Management NIDDM PTS on OHG /INSULIN require insulin +sub cut insulin POST OP IDDM AND NIDDM under severe stress need continuous IV infusion insulin
Slide 30 : Intra- operative Management During OR, Anesthetist monitors BS who has information about Pt; PAC( pre anesthesia check up should be done) Blood Sugar by Glucocheck,during and after OR Blood gas Monitor urine output EKG /BP monitoring
Slide 31 : DKA Restoration of IV Volume Correction of Acidosis Potassium replacement Blood Glucose IV Insulin
Slide 32 : DIABETIC GANGRENE Trophic changes due to peripheral neuritis Atheroma of arteries Excess sugar in the tissues Infection can spread along tissue planes and involve bone ---diabetic foot is major problem and lot of amputations can be avoided
Slide 33 : RULES FOR CARE OF DIABETIC PTS FEET Always wear roomy/comfortable shoes well padded Keep feet warm ,dry, clean Inspect feet daily , cotton between toes Avoid hot soaks or baths Trim toe nails and calluses expertly Get prompt medical attention for any injury or blister
Slide 34 : Thank u THANK YOU

 


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