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Surgery can be major or minor, planned or carried out as an emergency.
Sugar control is important before one undergoes surgery of any type.
A person with diabetes needs to have pre-operative fitness and simple
protocols are to be followed that would be understood by all the
staff.
In type 2 diabetes long acting sulphonylureas can be changed to
short acting ones some days before surgery. Metformin should be
stopped one week prior to surgery.
A person under going major surgery needs to be on parenteral nutrition,
usually intravenous. One should ensure he gets 150 g glucose in
24 hours to prevent ketosis.
All patients undergoing major surgery should be given insulin, usually
short acting, in multiple doses.
Monitoring sugar with the use of glucose meter during peri-operative
period has been successful in management of diabetes during this
period. Insulin is given according to the sugar value with help
of sliding scales.
Instructions for Management
of Diabetes for a Patient undergoing Surgery
Name:
Referring Surgeon:
Nature of Surgery:
Date and Time of Operation:
Instructions:
1. Pre-operative treatment till the day before
surgery:
2.
On the day of Surgery:
(a) [ ] No Insulin before Surgery
[ ] Inj: Plain Insulin/Actrapid MC/
…………………. Units S/c. at ……………
(b) Start one Bottle of 5% Dextrose-Saline/ ………………. Before Surgery
at ……..
3. After recovery from G.A./After Completion of Surgery (and return
to the room) Examine: -
[ ] Urine Sugar and Acetone (using Keto-Diastix)/
[ ] Capillary Blood Glucose (using Glucometer or …………………………………
) at [ ] 6.00 AM, 12 Noon, 6.00 PM, 10.00 PM and record in the table
given below (vide - Table).
4. Give injection plain Insulin/Inj. Human Actrapid Insulin or Humalog
(Lispro) subcutaneously at the timings noted above according to
the sliding scale given below: - (vide - Sliding scale).
5. I. V. Fluids as per Surgeons Instructions: ……………………………………… ………………………………………………………………………………………
Oral intake ………………………………………………………………………….
6. Maintain strict intake-output balance chart.
7. While on IV. Infusions ensure a minimum of 5 to 6 bottles of
Dextrose (5%) containing infusion. (i.e. 125 to 150 gms of Glucose
per day); when the patient is started on oral feeds - total carbohydrate
intake should be maintained at a minimum of 150 gms/day; if oral
feeds fall short of this, i.v. Supplementations are essential to
avoid Ketonuria/Ketosis.
8. Special Instructions if any:
SLIDING SCALE
Capillary
Blood Glucose (Glucometer)
Reading :Mgm/dl |
Urine
|
Insulin(Plain/Human
Actrapid) or UMALOG(LISPRO)Dose in Units |
|
Sugar
|
Acetone
|
| Below |
- |
150 |
|
|
|
|
|
|
|
| 151 |
- |
180 |
|
|
|
|
|
|
|
| 181 |
- |
210 |
|
|
|
|
|
|
|
| 211 |
- |
250 |
|
|
|
|
|
|
|
| 251 |
- |
280 |
|
|
|
|
|
|
|
| 281 |
- |
300 |
|
|
|
|
|
|
|
| 301 |
- |
350 |
|
|
|
|
|
|
|
| 351 |
- |
HI |
|
|
|
|
|
|
|
A Simple and Convenient Chart
for Assessing Daily
Blood Glucose Profile, Insulin Requirement
| |
Time
|
24 Hrs
|
|
Date
|
|
6.00A.M
|
12.00 Noon
|
6.00P.M
|
10.00P.M
|
Remarks
|
Intake
|
Output
|
| |
CBG(mg/dl)
|
|
|
|
|
|
|
|
|
Urine
|
Sugar |
|
|
|
|
|
|
|
| Acetone |
|
|
|
|
|
|
|
|
Insulin Dose
(Units)
|
|
|
|
|
Total Dose: |
|
|
| |
CBG(mg/dl)
|
|
|
|
|
|
|
|
|
Urine
|
Sugar |
|
|
|
|
|
|
|
| Acetone |
|
|
|
|
|
|
|
|
Insulin Dose
(Units)
|
|
|
|
|
Total Dose: |
|
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Insulin infusion using syringe
Driver/Pump
When
fluctuations of blood glucose are wide, in critical care conditions
(dehydration, water-logging of subcutaneous tissues, etc.) and when
parenteral steroids are being given in high doses, insulin should
be given continuously through iv route, through the Insulin filled
syringe driver at a preset hourly rate (e.g. 1 unit to 10 units
per hour), while blood glucose is monitored hourly, 2 hourly or
4 hourly as indicated by the patients condition. The 50 ml syringe
is filled with 50 units of either Human Actrapid Insulin or LISPRO
(Humalog) Insulin and normal saline upto 50 ml mark, so that 1 ml
per hour delivery is equivalent to 1 unit of insulin per hour and
so on.
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