Overview of Diabetes Intraoperative Management
According to the Centers for Disease Control, about 30.3 million Americans had diabetes in 2015. It’s also predicted that this number will increase every year. Currently, even more people, about 84 million, are at risk of developing diabetes. The people most likely to have diabetes are Alaska Natives and Native Americans, with African Americans, Hispanics, Asians, and Whites less likely to get the disease.
There are a few types of diabetes, but the most common ones are type 1 and type 2 diabetes. In type 1 diabetes, the immune system destroys special cells in the pancreas known as beta cells. These beta cells normally make insulin, but in type 1 diabetes, they can’t. This means that the person has to take insulin from an outside source for their whole life to keep their blood sugar levels normal. Often, type 1 diabetes develops in children, teenagers, or young adults. Sometimes, it isn’t discovered until the person has diabetic ketoacidosis. This is a dangerous condition where there is too much sugar and acid in the blood, and not enough insulin.
Type 2 diabetes, usually seen in older adults, is now affecting a broader age range due to increasing rates of obesity. This includes children and older individuals. Type 2 diabetes happens either because the body can’t use insulin properly, known as insulin resistance, or because the pancreas doesn’t produce enough insulin. Scientists aren’t exactly sure why this happens, but it’s believed to have something to do with changes in fatty acid levels inside our cells that might disrupt insulin function. Usually, at the time a person is diagnosed with type 2 diabetes, most of their pancreatic beta cells have stopped working properly. As the disease gets worse, the person may also need to take insulin from an outside source. However, changes in lifestyle, like eating less and losing weight, as well as medications that lower blood sugar levels, can help manage type 2 diabetes.
Anatomy and Physiology of Diabetes Intraoperative Management
Surgery and severe sickness can disrupt the body’s normal balance and lead to high blood sugar levels. These stress situations increase certain hormones in the body, like glucagon, adrenaline, cortisol, and growth hormone. This increases insulin resistance, meaning the body doesn’t use insulin effectively, and it boosts glucose (sugar) production in the liver. It also hampers the use of glucose in the body and can cause a shortage of insulin.
Adrenaline ignites the secretion of glucagon, a hormone that boosts blood sugar, and blocks the release of insulin by specific cells in the pancreas. Stress also leads to more fats being broken down in our body, which results in a high concentration of free fatty acids. High levels of these fatty acids could obstruct insulin’s ability to uptake glucose (sugar), limiting its ability to signal for the movement of glucose inside our muscles.
High blood sugar triggers the release of pro-inflammatory molecules, like tumor necrosis factor-alpha, interleukin 6, and interleukin 1B. High blood sugar can also hinder the functioning of white blood cells, affecting their ability to consume bacteria, move to infection sites, and destroy bacteria.
Abnormally high blood sugar can also result in an increase in reactive oxygen species, which can cause direct cell damage and further damage the blood vessels and immune system. This causes oxidative stress, which can lead to an increase in platelet aggregation; this means blood cells could start sticking together and forming clots easier, potentially causing blockages in your blood vessels.
Why do People Need Diabetes Intraoperative Management
Doctors diagnose diabetes when a patient meets at least one of the following conditions:
* Fasting blood glucose level of 126 mg/dL or higher. This means you haven’t eaten or drunk anything except water for at least 8 hours before the test.
* Random blood glucose level of 200 mg/dL or higher. This means that your blood glucose level can be tested at any time, even if you have eaten recently. This is done if a person is experiencing typical diabetes symptoms like feeling very thirsty, peeing a lot, or losing weight without trying.
* Blood glucose level of 200 mg/dL or higher two hours after having a special sugary drink. This procedure, known as an oral glucose tolerance test, is done to see how your body handles sugar.
* Hemoglobin A1C level of 6.5% or higher. Hemoglobin A1C is a type of protein in red blood cells that carries oxygen. It can tell your average blood sugar level over the past 2 to 3 months.
Equipment used for Diabetes Intraoperative Management
During an operation, the way diabetes is managed may need several items. These include:
* An Alaris pump and tubing: This is a device used to deliver fluids and medication into a patient’s bloodstream.
* A small bag (100 mL) of normal saline: This is a sterile mixture of salt and water. It’s often used for hydration and to dilute medications.
* Insulin: This is a hormone that helps control blood sugar levels. In people with diabetes, it may need to be administered to keep these levels in a safe range.
* Point of care glucose testing strips: These are special strips used to quickly check blood sugar levels. In some cases, a blood gas analysis using a sample from an artery or vein might be used instead.
* 50% dextrose: This is a concentrated sugar solution that can be used to quickly raise blood sugar levels if they drop too low.
Who is needed to perform Diabetes Intraoperative Management?
Patients with diabetes often receive care from a mix of healthcare professionals. This includes primary care doctors and specialists like endocrinologists – doctors who deal with illnesses related to the hormone system, including diabetes. When a diabetic patient needs to have surgery, it’s important for all the healthcare professionals involved in their day-to-day care to also be involved in preparing for the operation.
The person who should give the patient instructions on how to prepare for the surgery is usually the healthcare professional who knows the patient best and feels best equipped to give the right advice. And in most circumstances, the surgical team should talk with the patient’s usual healthcare team to get advice on how to manage the patient’s diabetes during the operation.
The anesthesia team – the group responsible for making sure the patient is asleep and doesn’t feel any pain during surgery – should also try to get accurate information from anywhere the patient gets care. They need this information to decide on the best way to manage the patient’s blood sugar during the operation.
How is Diabetes Intraoperative Management performed
There aren’t any strict laws or rules regarding the need to cancel a surgery if a patient’s blood sugar levels are too high. The Society for Ambulatory Anesthesia, an expert group on outpatient anesthesia, suggests stopping a surgery if a patient is in a state of diabetic ketoacidosis (a severe, life-threatening complication of diabetes), hyperglycemic hyperosmolar nonketotic state (another potentially fatal complication of diabetes), or is severely dehydrated.
On the day of the surgery, if a patient has a blood sugar level over 140 milligrams per deciliter (mg/dL), it’s important to check their blood glucose levels every 2 hours during the surgery. This can be done using a pointer device that takes blood samples from the patient’s artery or a line inserted in their vein.
If a patient’s blood glucose level is 180 mg/dL or higher and they are in a critical condition, an intravenous (IV) insulin drip should be started. Insulin is a hormone that helps control blood sugar levels. The initial dose of insulin in the drip can be calculated by dividing blood glucose by 100. Blood sugar levels should be checked every hour because insulin works quite quickly, with a half-life of 35 minutes.
For patients who are not critically ill and have a short surgery (less than 4 hours) which doesn’t generally cause large changes in body fluid levels, it’s better to use fast-acting insulin that is injected under the skin. Instructions on how to dose this type of insulin on the day of surgery are provided for patients who are sensitive to insulin (those without a history of diabetes), those who are resistant to insulin (those who need more than 80 units of insulin per day, have a Body Mass Index over 35 or take more than 20 mg of prednisone), and those who require usual amounts of insulin (all other cases).
Possible Complications of Diabetes Intraoperative Management
During surgery, controlling high blood sugar levels is really important, especially for folks with diabetes. If sugar levels aren’t managed well, it can lead to a 50% increase in health complications and death rates for diabetic patients compared to those without diabetes. In fact, studies show that high sugar levels during surgery can lead to longer hospital stays, slower healing, and a greater chance of serious post-surgery complications, like lung infections (pneumonia), bloodstream infections, bladder infections (urinary tract infection), kidney failure, and heart attacks.
When treating high blood sugar levels with insulin, some potential problems can arise. One such complication is a condition called hypokalemia, which is a fancy term for low levels of potassium in the blood. This is especially likely when diabetes leads to a condition called diabetic ketoacidosis. Insulin can drive potassium out of cells and into the blood, and with lots of insulin in your system, too much potassium can be lost in the urine. This can also lead to low levels of other essential minerals like calcium and magnesium, and can affect your heart rhythm.
Another potential risk from insulin treatment is hypoglycemia, which means dangerously low blood sugar levels. People treated with a strict blood sugar control strategy are five times more likely to experience severe low blood sugar after surgery compared to those with more flexible blood sugar control. Signs of hypoglycemia include shaking, sweating, feeling dizzy or lightheaded, having seizures, and even passing out. If someone has low blood sugar during surgery, it can delay their recovery from anesthesia until they’re given glucose to bring their blood sugar back to normal.
What Else Should I Know About Diabetes Intraoperative Management?
In the medical field, especially among anesthesiologists, there’s no single standard approach regarding the desired levels of blood glucose (sugar in the blood). But generally, everyone agrees that the blood glucose levels should be kept under 180 mg/dL (milligrams per deciliter) to avoid any risks. Keeping it too low might result in a condition known as hypoglycemia, which is when the sugar levels in the blood are too low.
Recent research compared the differences between maintaining very tight control (keeping blood glucose lower than 110 mg/dL), tight control (blood sugar levels between 111-150 mg/dL), and liberal control (blood sugar level lower than 220 mg/dL) in patients’ health and survival rates. Interestingly, they found that there’s no significant difference in the death rates between these groups.
However, patients in the tight control group did show fewer adverse events. These included a lower chance for surgical site infections, acute kidney injury (sudden damage to your kidneys), sepsis (a life-threatening reaction to an infection), and atrial fibrillation (an irregular and often fast heartbeat).