Diabetes and surgery

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Diabetes and surgery
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Diabetes mellitus (DM), also known as
simply diabetes, is a group of metabolic diseases
in which there are high blood sugar levels over a
prolonged period
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• any one of the following-
• Fasting plasma glucose level  7.0 mmol/l
  (126 mg/dl)
• Plasma glucose  11.1 mmol/l (200 mg/dl) two
  hours after a 75 g oral glucose load as in a
  glucose tolerance test
• Symptoms of hyperglycemia and casual plasma
  glucose  11.1 mmol/l (200 mg/dl)
• Glycated hemoglobin (Hb A1C)  6.5.

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• Serious long-term complications include heart
  disease, 
• stroke, 
• kidney failure,
•  foot ulcers and 
• damage to the eyes.

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• Type 1 DM results from the body's failure to
  produce enough insulin. This form was previously
  referred to as "insulin-dependent diabetes
  mellitus" (IDDM) or "juvenile diabetes". The
  cause is unknown.

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• Type 2 DM begins with insulin resistance, a
  condition in which cells fail to respond to
  insulin properly. As the disease progresses a
  lack of insulin may also develop. This form was
  previously referred to as "non insulin-dependent
  diabetes mellitus" (NIDDM) or "adult-onset
  diabetes". The primary cause is excessive body
  weight and not enough exercise.

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• Gestational diabetes, is the third main form and
  occurs when pregnant women without a previous
  history of diabetes develop a high blood glucose
  level.
• Type 1 diabetes must be managed
  with insulin injections.
• Type 2 diabetes may be treated with medications
  with or without insulin.

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• Surgical complications of Diabetes are due to
• 1) Micro vascular changes involving the
• capillaries of retina, kidneys, and peripheral
• nerves.
• 2) Macro vascular changes characterized by
• atherosclerotic lesions of the coronary and
• peripheral arterial circulation.
• 3) Diabetic neuropathy.
• 4) Infection in glucose loaded tissue.

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Surgical complications in Diabetic Patient

• Bacterial infections like abscesses,
  carbuncles,
• chronic balanitis, and diabetic foot.
  Emphysematous Cholecystitis, Emphysematous
  Pyelonephritis, Necrotising fasciitis and
• Fourniers gangrene
• Fungal infections like candidiasis, Mucormycosis.
• Sexual dysfunctions

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• Diabetic foot
• Most feared and devastating complication of
• diabetes
• Most common cause for leg amputations
• The classic pathological triad of the diabetic
• foot is vascular disease, neuropathy and
  infection

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Wagners classification for diabetic foot

• Grade 0 High risk foot. No ulceration
• Grade 1 Superficial ulceration
• Grade 2 Deep ulceration penetrating up to
  tendon, bone or joint
• Grade 3 Osteomyelitis or deep abscess
• Grade 4 Localized gangrene (Toes or fore
  foot)
• Grade 5 Extensive gangrene (mid foot or hind
  foot) requiring major amputation

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Neuropathic foot

• Sensory, autonomic and motor neuropathy
  contribute
• to the pathogenesis of Neuropathic foot.
• Motor weakness leads to atrophy of the small
  muscles of the foot with an imbalance between the
  flexors and extensors. This results in clawing of
  the toes and prominent metatarsal heads.
• High foot pressure develops under the
  metatarsal heads.
• Dry, brittle skin (as a result of autonomic
  neuropathy)
• and high foot pressure lead to callus formation.
  The
• callus can cause tissue damage and ulceration.

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Diagnosis and assessment of diabetic foot

• Thorough neurological examination to detect
• sensory, motor or autonomic nerve deficit.
• H/o rest pain, intermittent claudication.
  Examination
• of peripheral pulses, capillary filling.
• Doppler study.
• Estimation of blood glucose, Hb.TLC,DLC, urea,
  creatinine
• and lipids.
• X-ray to detect osteomyelitis

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Management of diabetic foot

• Infections are treated by wound debridement,
• proper antibiotic, multiple insulin
  injections to achieve good control of blood
  glucose.
• Exercise, cessation of smoking. Use drugs like
• pentoxyphylline, aspirin, and thrombolytic
  agents to
• improve blood supply.
• Angioplasty, bypass, stenting, atherectomy and
  laser
• ablation of atherosclrotic plaque

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• Attempt to convert wet gangrene to a dry one
• by repeated dressings and proper antibiotics.
• Once gangrene sets in, decide for amputation.

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Surgery in diabetic patients

• Diabetic patients are prone to develop sudden
  hyperglycemia or hypoglycemia during surgery. So,
  frequent monitoring of blood glucose is
  necessary.
• Short acting insulin is given during surgery
  and in the immediate postoperative period.
• They are admitted a few days ahead of surgery.

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• Oral hypoglycemic drugs are stopped a few days
  before major surgery and insulin is started, to
  bring about better control of blood sugar.
  Insulin is continued for a few days in the
  postoperative period also.
• Wound healing is likely to be delayed

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• Q1-Dibetes mellitus is defined when in glucose
  tolerence test ( 75 g glucose followed by blood
  sugar measurement, after 2 hr) is
• A. less than 140 mg/dl
• B. between 140-200
• C. gt200 mg/dl
• D.180 mg /dl

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• 2.Long term complication of DM is-
• a.Heart disease
• b. renal disease
• c. diabetic foot
• d. all above

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• 3.Most common cause for leg amputation-
• a.venous ulcer
• b.trauma
• c.Buerger disease
• d. diabetic foot

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• 4.Grade 3 diabetic foot ( wager classification)-
• a.superficial ulcer
• b.deep ulcer exposing bone, joint,tendon
• c.osteomyelitis
• d. gangrene

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• 5. A diabetic pt on oral hypoglycemic agent is
  planned for surgery, which one is true-
• a. oral hypoglycemic drug should not be stopped
• b.oral hypoglycemic agent should be stopped few
  days before surgery and long acting insulin
  should be started pre and post op
• c.oral hypoglycemic agent should be stopped few
  days before surgery and short acting insulin
  should be started pre and post op for few days

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• 6. In diabetic patient level of Glycated
  haemoglobin (HB A1C) is more than
• 8.0
• 6.5
• 4.5
• d. 9.2