MANAGEMENT OF

PERIOPERATIVE ON
DIABETIC PATIENTS
dr Budi Enoch SpPD
 DIABETES MELLITUS

a chronic metabolic disorder with the

prevalence in Indonesia is 4%
(Perkeni 2002)

prevalence of diabetes case in

hospital is 12.4-25% (Clements et
al,Diabetes Care 27,2004)
 DIABETES MELLITUS

maintenance normoglycemia can

decrease incidence of wound infection,
major cardiac complication and
mortality on intensive care unit

(Lazar HL, Circulation 109,2004)

 my team:
MY TEAM
Endocrinologist
Primary Care
Anesthesiologist
Surgeon
Nurse
Dietician
Mr X
Ms Y
Metabolic response to surgery
Surgery and anesthesia lead to elevation of
sympathetic tone that release cortisol and
catecholamine during surgery
These lead to relative insulin hyposecretion,
insulin resistance and increased catabolism
protein
Inhalational agents suppressed insulin
secretion
Metabolic response to anesthesia and surgery
 Postoperative infections

Sherita Hill et al. Diabetes Care 22(9), 1999

PREOPERATIVE ASSESSMENT
Complete history and physical examination
Complete cardiac evaluation for undergoing
major surgery
Treat hypertension
Status of peripheral circulation and the
sensory nerves
PERIOPERATIVE
MANAGEMENT
1. WELL-CONTROLLED
TYPE 2
2. POORLY CONTROLLED
TYPE 2
3. TYPE 1
The perioperative sliding scale
Serum Glucose level Regular Insulin
150-200 mg/dl 2 unit of regular insulin
201-250 mg/dl 4 unit of regular insulin
251-300 mg/dl 6 unit of regular insulin
301-350 mg/dl 8 unit of regular insulin
greater than 350 mg/dl 10 unit of regular insulin
 Intraoperative management (well-
controlled type 2)

Type of anesthetic, stress of the procedure

and patient’s response
Patients who require insulin coverage should be
monitor using protocol for type 1 diabetes
In stable patients, monitor limited to the
preoperative and postoperative periods
 Preoperative management (poorly
controlled type 2)

Prior to surgery, fasting > 125 mg/dl and 2h-

pp > 180 mg/dl
If converted to insulin coverage, continue until
the stresses abated
Require newly tailored therapeutic
Oral agents are restarted when eating are
normal
Sliding scale added if requires
PERIOPERATIVE INSULIN
REGIMENS FOR TYPE 1
Sliding scale regimen still give the ‘roller
coaster’ effect
Improvement showed on GIK solution
(infusing 5-10 g dextrose, 1-2 unit insulin ,
potassium and 100-125 ml fluid per hour) to
mimic steady-state physiology
Using a continuous insulin infusion pump
Variable rate iv insulin infusion
Mix 100 unit short acting in 100 ml normal
saline (1 unit = 1 ml )
Start insulin infusion at 0,5 to 1 unit per
hour
Start separate infusion of 5% dextrose at
100 – 125 ml/hour
Monitor glucose hourly or every 2 hours
when stable and adjust as :
blood glucose level action
(mg/dl)
below 70 Turn off insulin for 30’
Still below 70, give 10 g
glucose and recheck
every 30’ until above
100 mg/dl then restart
infusion and decrease
rate by 1 unit per hour
blood glucose level action
(mg/dl)
71 – 120 Decrease 1 unit/hour
121 - 180 Continue as is
181 – 250 Increase 2 unit/hour
251 – 300 Increase 3 unit/hour
301 – 350 Increase 4 unit/hour
351 – 400 Increase 5 unit/hour
Above 400 Increase 6 unit/hour