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Under the Knife

Posted on November 19, 2021 | No Comments on Under the Knife

When a diabetic undergoes surgery. People with diabetes may undergo surgery due to complications such as cardiovascular problems and infection that may develop in their bodies or due to other conditions unrelated to their diabetes. During these times, people with diabetes must adhere to certain special requirements and considerations to help ensure surgical success.

According to Dr. Florence Amorado-Santos of the American Association of Clinical Endocrinologists-Philippine Chapter, (AACE-PC) “A diabetic person undergoes almost the same types of surgery that a non-diabetic person does. However there are specific procedures that are commonly done in diabetic patients which are usually due to infection such as ray, below or above the knee amputation, debridement of non-healing wounds and gangrene.”

During these times, it is important to closely monitor metabolic processes, maintain the necessary amount of fluid and caloric repletion, and availability and judicious use of insulin. These processes are taken into consideration not only during the procedure itself but even before and after it.

Pre operative assessments indicate the preparations and processes to monitor before the surgery takes place. First and foremost, it is significant to know whether the patient has poorly controlled diabetes or not. Secondly, the physician or endocrinologist should check whether there is a presence of any other co-morbid condition that would need treatment and would warrant pre-admission to the hospital.

According to Dr. Santos, such evidence of ischemic heart disease, cerebrovascular disease, and kidney dysfunction should be sought. It is also important to note the anti-diabetic regimen that the patient has. “If the patient is receiving oral hypoglycemic agents, they may be continued until the evening prior to the surgery, remembering that these drugs may produce hypoglycemia several hours after their administration in the absence of food intake. Those having insulin regimen may also need adjustments for their insulin doses prior to the procedure,” says Dr. Santos.

Part of the preoperative assessment is to assess the kind and amount of anesthesia that will be used for the operation, and the extent to which the patient’s body can handle it. The reason behind this is that anesthesia during surgery of diabetics can result in metabolic stress responses that can lead to insulin resistance, gluconeogenesis, and high blood sugar.

Also, it can lead to the release of catabolic hormones such as epinephrine, norepinephrine, cortisol, glucagons, and growth hormones. It has even been observed that epidural anesthesia, spinal blocks, and splanchnic nerve blocks ameliorate the endocrine and metabolic response.

Dr. Santos emphasizes that epidural and low spinal anesthesia can preserve glucose tolerance, presumably due to the inhibition of the counter regulatory hormone epinephrine as a response to surgery.

From the study of Dronge et al (2006), good preoperative glycemic control with an HbA1c level of less than 7% is associated with lower risk of postoperative infections (such as pneumonia, wound infection, urinary tract infection, and sepsis) when adjusted for other factors that are known to influence this outcome.

Dr. Santos explains that according to the American Diabetes Association, observational studies among surgical patients whose blood glucose levels are not within target (>220 mg/dL), have higher rates of infection. Longer hospital stay and frequent ICU admissions were also noted for these patients. Surgical patients with fasting glucose of. less than 126 mg/dl and all random glucose levels of less than 200 mg/dL have better outcomes.

The intraoperative period begins when the patient is transferred to the operating room bed and ends when the patient is transferred to the post-anesthesia care unit. During this period, the patient is monitored, anesthesized, prepped, and draped, and the operation is performed.

Intravenous infusion of fluid such as insulin, potassium, and glucose is necessary during the surgery of a type 1 diabetic, or a special case type 2 diabetic. These are administered in order to maintain volume in the blood vessels. The surgical process in type 2 diabetic patients involves two main determinants. First, there is the magnitude of the intended surgical procedure (if it is a major or a minor surgery), and second, there is the metabolic state of the patient on the day of surgery.

Rifkin, et al states that the patient who is well-controlled on diet alone, or diet plus oral agents does not require any specific therapy for minor surgery. There is more argument as to how the poorly controlled type 2 diabetic patient should be treated . for minor surgery. Some still advocate no specific therapy, but on occasion an insulin infusion regimen would seem appropriate. Many different regimens have been suggested for metabolic control during major surgery in type 2 diabetics.

The authors also maintain that it is logical and simple to use the same regimen as for type 1 diabetics, as this gives similar results in terms of glycemic regulation. Close monitoring of the blood glucose and maintaining its level is necessary all throughout the procedure to avoid further problems such as high blood sugar, very low blood pressure, electrolyte imbalance, and diabetic ketoacidosis (DKA).

Aside from the constant monitoring and maintenance of the blood glucose level in patients, it is highly important for them to comply with the medications, whether oral hypoglycemics, insulin, antibiotics, and cardiac drugs. Adjustment of medications for diabetes after surgery is common. These are done to have good glucose control vital to wound healing. According to Dr. Santos, some patients may need to be shifted to insulin regimen during their recovery period.

Aside from that, she also maintains that any note of signs and symptoms of post-operation complications such as non-healing incisions, pus draining from surgical wounds, fever and chills should be brought to the immediate attention of the attending physician.

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