糖尿病（dm）手术课件

Surgery In Diabetes Mellitus (DM) Walid Sayed Abdelkader Hassanen Specialist of internal Medicine March 2010 1 2 Surgery In Diabetes Mellitus Hyperglycemia leads to impaired wound healing , deficient formation of granulation tissue. The chemotactic , phagocytic, and bacterial activity of the neutrophil is deficient , there is impaired hormonal host defense mechanism and abnormal complement function. 3 Metabolic sequelae in a surgical patient Increased glycogenolysis Increased gluconeogenesis hyperglycemia Decreased glucose utilization: Lipolysis with increased FFA Protein breakdown Increased nitrogen loss Increased urea production Increased sodium retension & potassium execretion and alteration of water metabolism ( increased ADH and increased aldosterone secretion ) 4 Determinents of the management plan 1.Type of DM 2.Treatment, diet, oral antidiabetic drugs, insulin 3.Metabolic status 4.Vascular status: cardiac, renal, cerebral 5.Surgery: Type: emergency or elective Minor or major procedure Type of anesthesia Post operative oral intake 5 Pre-operative management Metabolic stress of surgery and anesthesia cause increased elaboration of catecholamins, glucocorticoids, glucagon, and growth hormone, all producing their metabolic effects resulting in hyperglycemia in the pre-operative period. The glycemic control is aimed to achieve a fasting plasma glucose of 300 mg % 8-10 U are added to normal saline and surgery is delayed for few hours till satisfactory glycemic control is achieved. All the above infusions are given at the rate of 100-120 ml / h . 11 Post operative management With the resumption of oral feeds subcutaneous insulin can be started, NIDDM patients can resume their oral antidiabetic drugs after week if there is no complications of surgery. 12 Intravenous fluids 1.Dextrose saline / normal saline is used if blood pressure is low or normal. 2.If there is hypertension half normal saline or 5 % dextrose is given. 3.For normal metabolism 50 gm glucose is required every 8 hours for energy and to avoid ketosis, to meet this demand at least 1000 cc 5 % glucose every 8 h will be required. 4.In situations requiring fluid restriction 10 % dextrose can be infused instead of 5 % with double the dose of insulin. 13 Practical aspects 1.Whatever is the pattern of infusion, the blood sugar has to be checked every tow hours and the flow rate is adjusted. 2.Intra and post operative potassium monitoring is done and corrected appropriately. 3.A few hours after surgery there will be reduction in the insulin requirement as the elevated counter hormones due to surgical stress decline. 14 Emergency surgery In emergency surgery it is deal to use intravenous insulin infusion. 15 Minor surgery For minor surgery the antidiabetic drugs and insulin are stopped on the day of surgery, once the surgery is over and the patient is permitted to resume oral feeds the antidiabetic drugs are started with half the dose which the patient was originally taking, on the second post operative day full dose of the oral drugs and or insulin are started. 16 Special situations 1.Blood sugar may rapidly fall after surgical drainage of an infected area. 2.Type 2 diabetes can be safely switched over to oral drugs after a week. 3.In coronary artery bypass surgery and during and after renal transplantation the insulin requirements will be exceptionally high. 17 Our aim To make patients safe for surgery, for this we need an understanding team work betw