Diabetes Mellitus

Pre-operative assessment
A chronic condition which affects ±10% of the general population,
characterized by ↑ serum glucose and a relative or absolute ↓ in pancreatic
insulin production, or ↓ tissue responsiveness to insulin; if not properly
controlled, the excess glucose damages blood vessels of the eyes, kidneys,
nerves & heart.

Types:
• Type 1 : Characterized by loss of the insulin-producing beta cells of
the islets of Langerhans in the pancreas leading to insulin deficiency.
• Type 2 : Characterized by insulin resistance which may be combined
with relatively reduced insulin secretion.
• Gestational DM : Resembles type 2 diabetes in several respects,
involving a combination of relatively inadequate insulin secretion and
responsiveness. It occurs in about 2%–5% of all pregnancies and may
improve or disappear after delivery.
• Secondary DM : A rare condition caused by some drugs or after
certain surgeries.

Diagnosis:
Diagnostic Criteria for Diabetes Mellitus by American Diabetes
Association:
1. Symptoms of DM plus random plasma glucose level >200 mg/dL .
2. Fasting plasma glucose level >126 mg/dL .
3. Two-hour plasma glucose level >200 mg/dL during oral glucose
tolerance test .
Morbidity and mortality:
Hyperglycaemia: Leading to dehydration, acidaemia, poor wound healing
and increased susceptibility to infection.

Hypoglycaemia: May progress to brain damage, pulseless electrical

activity and even death if not treated.

Cardiovascular: Accelerated atherosclerosis and generalized micro-

vascular disease leading to coronary heart disease, hypertension and
peripheral vascular diseases.

Neurological: Autonomic neuropathy (postural hypotension, gastroparesis,

bladder dysfunction), peripheral neuropathy with typical glove and
stocking distribution.

Renal: Diabetic nephropathy is the commonest cause of ESRF.

Ophthalmic: Cataract, exudative and proliferative retinopathy.

Respiratory: Increase incidence of infections including TB.

Diabetic coma: As sever hypoglycaemia, diabetic ketoacidosis and

hyperosmolar non-ketotic coma.

Implications for anaesthesia:

• Starvation may cause hypoglycaemia particularly in the presence of
long acting hypoglycaemic agents.
• General anaesthesia or sedation may mask the symptoms of
hypoglycaemia.
• The stress response to surgery results in increased catabolic hormone
secretion which may worsen hyperglycaemia.
• Circulatory disturbance during anaesthesia and surgery may affect the
absorption of subcutaneous insulin.
Organ reserve:
Normally glycogenolysis, glycogenesis and proper pancreatic
response (for increased or decreased blood sugars by insulin or glucagon
secretion respectively) can keep the blood sugars tightly controlled.

These mechanisms may fail due to effect of disturbed hormonal

secretion, infections (especially Viral infection of pancreatic B cells) and
side effects of certain drugs.

Reversible illness:
Chronic DM can be controlled by oral hypoglycaemics, insulin and
insulin sensitizers either single or combined.
Vitamins and other drugs that improve peripheral circulation may
improve the outcome.
Tight control of DM delay the appearance of complications and
hasten them.

Peri-operative control of DM:

Depend on the type of DM, proposed surgery and NPO duration.

• Type 1 DM with good glucose control undergoing minor surgery

where an early return to oral intake is anticipated are managed with a
variety of regimes including:
◦ No insulin/No glucose.
◦ Omission of short acting insulin and administration of one-third of
the dose of intermediate or mixed insulin on the morning of the
surgery.
◦ Administration of one-half of the normal insulin dose on the
morning of surgery followed by 5% glucose infusion.
• Type 1 DM undergoing major surgery (with good or poor glucose
control) is best managed by intravenous insulin and glucose regimen,
There are two main types of regimens in use:
◦ Glucose-insulin-potassium systems such as the Alberti regimen.
 ◦ Separate infusions of insulin and 5% or 10% glucose which
contain potassium.
• Type 2 DM with good glucose control undergoing minor surgery
should omit the morning dose of their oral hypoglycaemic agent and
restarted soon after oral intake is resumed.
• Type 2 DM who are poorly controlled or who are undergoing major
surgery should be converted to glucose and insulin regimen as type 1.

Notes:
• Diabetic patients should be on early on the morning surgery list.
• Metformin should be stopped 2 days before surgery or lactic acidosis
may be developed.

Mohammed Sayed Mohammed.

Junior anaesthetist.
el-Mabaraa Hospital, Tanta, Egypt.