CHAPTER 39

ANAESTHESIA AND DIABETES MELLITUS

Outline:

The diabetic patient

Management of diabetes

Anaesthetic management of the diabetic patient

Principles
Peri-operative regimes

205
THE DIABETIC PATIENT

Diabetes mellitus is a clinical condition characterised by hyperglycaemia. It

is caused by a deficiency, or diminished effectiveness of insulin in the body.
The action of insulin
The main action of insulin is to help the entry of glucose from the blood into
the cells where it is stored as glycogen. If insulin is deficient then the
following changes occur:
• The blood glucose is not converted into glycogen and stored. This
results in hyperglycaemia. The high blood sugar spills over into the
urine and therefore the patient has glycosuria.
• Fat metabolism is increased to supply energy. The products of fat
metabolism (ketones) appear in the urine and blood.
• Protein metabolism. The synthesis of protein in the body is slowed
down in diabetes and therefore muscle wasting occurs.
The symptoms and signs of diabetes
• Polyphagia (excessive hunger)
• Polyuria (excessive urine output)
• Polydipsia (excessive thirst)
• Ketones are acid in nature. An excessive accumulation of ketones
causes the patient to develop a metabolic acidosis (or ketosis). This is
associated with dehydration and electrolyte imbalance.
The patient with uncontrolled diabetes may present with collapse and
coma due to metabolic acidosis (ketosis).
• Other signs of diabetes mellitus include wasting and infections which
will not heal. TB is more common in diabetics.
Symptoms of secondary involvement of other organs are
− Peripheral vascular disease
− Heart disease
− Renal disease
− Peripheral neuritis
− Eye disease

206
Diabetic coma
The differences between
coma from hyperglycaemia coma from hypoglycaemia
General Condition
Cold, dehydrated, having sunken Pale, sweating, large pupils,
eyeballs, breath smelling of acetone, hyperactive reflexes
sluggish reflexes
Respiration
Deep sighing Normal
Circulation
Low blood pressure Normal blood pressure, tachycardia

In addition to the symptoms and signs given in the table, the patient’s
history aids diagnosis.
A history of gradual onset of coma, or a longer period of illness before the
coma suggests hyperglycaemia. Hypoglycaemic coma has a sudden onset.
A history of missing a meal, after taking the usual dose of insulin, suggests
hypoglycaemia.
A coexisting secondary infection tends to upset the diabetic state and it is
common to find patients developing hyperglycaemic coma.

MANAGEMENT OF DIABETES

Diabetes is usually treated by one of three methods:

Diet alone
About 30-35 cal/kg (125-145 J/kg) are divided as follows:
50% as carbohydrate
30% as fat
20% as protein
Oral hypoglycaemic agents
Older patients and milder diabetics can be treated with oral drugs.
Tolbutamide, chlorpropamide and glibenclamide are examples.
Insulin The following categories of patients are treated with insulin:
• Juvenile or unstable diabetics
• Those not responsive to oral therapy
• Those presenting with severe infections or those presenting for major
surgery.

207
There are various types of insulin

Peak action
Short acting s/c 2-4 hrs soluble insulin Actrapid
medium acting 4-8 hrs isophane insulin
long acting 8-12 hrs protamine zinc insulin,
ultralente

Insulin preparations vary from country to country so it is best to become

familiar with what is available locally.

ANAESTHETIC MANAGEMENT OF DIABETIC PATIENTS

PRINCIPLES
• It is always safer to have a patient hyperglycaemic under the
anaesthetic than hypoglycaemic.
• Patients for elective surgery must not be anaesthetised unless their
diabetic state is well controlled.
• A regional technique, if suitable, is the first method of choice.
• Place the diabetic first on the operating list, if possible, to minimise the
period of fasting.
• Diabetes affects the heart, the blood vessels and the kidneys, so these
systems should be investigated, especially in the case of long standing
diabetes. The following tests are recommended: chest x-ray, ECG,
serum electrolytes, random blood sugar, and urinalysis.
• Ether is associated with a rise in blood sugar, but a low concentration
of ether is not contraindicated in diabetics.
• The scheme of control: textbooks describe various methods of
management for diabetics undergoing surgery. It is best to get familiar
with one or two methods. Two methods will be described below.

208
PERI – OPERATIVE REGIMES

The anaesthetic management depends on whether the diabetes is controlled

or uncontrolled, whether the surgery is major or minor, and whether it is
elective or emergency.

Controlled diabetes and major surgery

First method using sliding scale of soluble insulin

On the day of surgery withhold the usual dose of long acting insulin or oral
medication and commence and stabilise the patient on a sliding scale of
soluble insulin. The actual dose of insulin depends on the amount of glucose
in the blood or urine. The following scales are practical and useful.
Sliding scale based on 4-hourly glucometer readings

mmol/l mg% soluble insulin

0-4 < 72 0 units
4.1 – 8 73-144 4 "
8.1 - 12 45-216 6 "
12.1 – 16 217-290 8 "
16.1 - 20 91-360 12 "
> 20 >360 Seek advice

On the morning of operation commence a 5% dextrose infusion running at

30 drops/min until the patient comes to theatre.
Add 10 mmols KCl to each 500mls of 5% dextrose.
Perform four-hourly blood sugar and urinalysis and give insulin treatment
according to the scale. The bladder must be completely emptied after each
sample of urine is taken for examination.

Second method using longer acting insulin

• Start a 5% dextrose infusion on the morning of the operation. The fluid
runs in at the rate of 30 drops/min.
• Give half the usual dose of long acting insulin on the morning of the
operation.
• Continue four-hourly blood sugar and urinalysis.
• Test blood sugar on the evening of the operation, and give a further
dose of insulin if necessary.
For other regimes consult World Anaesthesia journal Update no 11
(2000)
209
 Controlled diabetes and minor surgery
In the case of the patient with controlled diabetes who presents for minor
surgery, the usual anti-diabetic treatment (i.e. insulin or tablets) is not given
on the morning of the operation. A 5% dextrose drip is commenced in the
OR, and normal medication is resumed the next day provided the oral intake
of food is adequate.
Uncontrolled diabetes
Elective surgery: The diabetes must be treated and controlled before
surgery is performed.
Emergency surgery: If ketones appear in the urine (even if the
operation is an emergency) you must try to delay surgery until the
diabetic state is treated. This may take 8-12 hours. The acidosis and
electrolyte disturbance must be corrected first, if possible.
Regime for management of ketoacidosis
• Rehydration
Give 1 litre 0.9% saline over 30 mins
Give 1 litre 0.9% saline over 1 hour
Give 1 litre 0.9% saline over 2 hours
Continue 2-4 hourly until blood glucose is controlled then continue
with 5% dextrose 1 litre 2-4 hourly.
• Reduce blood sugar level
Give 20 units soluble insulin IM then 6 units IM hourly.
Check blood glucose hourly.
When blood glucose is < 15 mmol/l change to 6 units IM 2 hourly.
When patient is eating and drinking change to S/C insulin.
• Potassium supplementation
Add 10mmol KCl to the first litre of saline. If potassium measurements
are available this can be adjusted as required otherwise continue with
10mmol KCl / litre of fluid.
Emergency surgery can start once this treatment regime is established.

210