Diabetes and Surgeon

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lida on Nov 28, 2011 Says :

thanks,that was excellent.

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Slide 1 :

DIABETES RELATED TO SURGERY DR;Fiaz Maqbool Fazili Senior Surgeon Specialist, King Fahad Hospital Medina Munawarah KSA; DIABETES RELATED TO SURGERY Fiaz Fazili

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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

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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

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Diabetes prevalence Diabetes has world wide distribution seen in developed countries; about 6 million people in USA have diabetes; additional 4-5 million have undiagnosed Diabetes.Prevalence of Diabetes in USA 300/100,000 in 1973;230/100,000 in 1981.Prevalence continues to increase>about 10,000 people in USA develop IDDM each year. 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.

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Magnitude Of problem Diabetes is responsible for about 38,000 deaths each year in USA.(NDDGR_USA) Diabetes is a major cause of new cases of blindness –diabetics are 25 times more likely than non diabetics to develop blindness; 7 times more likely to develop renal disease; 20 times more likely to develop gangrene; Twice more likely to develop heart disease or suffer stroke; about 10% diabetics undergo major amputation during life time ;over 80% of major amputations IN USA in diabetics; 14% Diabetics are bed ridden for an average of 6weeks per year.total impact of diabetes was estimated more than 14 billion dollars in 1989 including medical expenses,lost time from work and so forth

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LET NOT AUTUMN FALL ON u Early TREAT DIABETES EARLY AND REGULARLY

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DIABETES TYPES DIABETES TYPES TYPE I TYPE II Secondary Drug Induced

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DIABETES TYPES-JUVENILE IDDM-juvenile onset DM 20% of all Diabetics Onset in childhood Insulin dependant Prone to Ketosis and acidosis

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DIABETES TYPES -ADULT Non insulin dependant Above 30 yrs –Obese Insulin resistance is common Less prone to ketosis and acidosis.

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DRUG INDUCED Thiazides Corticosteroids

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SECONDARY DIABETES Pancreatic Insufficiency Haemochromatosis Following Pancreatic Surgery

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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

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Metabolic derangement Hyperglycaemia Acidosis Hyperlipaedaemia

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Problems in Diabetics Macrovascular disease Peripheral arterial disease Coronory arterial disease(silent CAD) Mesentric vascular insufficiency Cerebral vascular insufficiency

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CAUTION MI often with an atypical presentation is the leading cause of perioperative death among Diabetics CAUTION CAUTION

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Chronic complications Neuropathy(autonomic dysfunction) Postop Hypotension Urinary retention Gastro paresis Nephropathy Fluid and Electrolyte imbalance ARF Retinopathy

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INFECTION AND DIABETES Common infections Pyelonephritis Papillary necrosis Perinephric abscess Unusual infections Necrotizing fascitits Gingivitis &pyorrhea Malignant O.E Fungal infections

Slide 18 :

Diabetes-Infection PNL function deranged Chemo taxis is less Phagocytic activity is deranged Intracellular bactericidal activity is reduced

Slide 19 :

PRE OP ASSESSMENT History Complications H/o heart disease Drug history Symptoms of infection

Slide 20 :

Pre op Asessment-Phy- Exam Opthalmoscopy Blood pressure Circulation Neurological exam Status of feet

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Pre op assessment-lab work Blood glucose, serum Na, k, NaHco3 Renal function Cardiac evaluation-EKG,RIS, CORONORY ANGIO

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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

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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

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DIET Controlled -NIDDM Can be maintained safely without food or glucose infusion prior to surgery

Slide 25 :

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 26 :

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 27 :

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

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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

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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

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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

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Intra- operative Management During OR, Anesthetist monitors Blood Sugar who has prior 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 32 :

DKA Restoration of IV Volume Correction of Acidosis Potassium replacement Blood Glucose IV Insulin

Slide 33 :

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 34 :

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 35 :

Thank u THANK YOU

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