PERI-OPERATIVE CARE

The Diabetic Patient

How do you assess a diabetic patient in the clinic?

Take a history of the type of diabetic control used, the dosage schedule and the adequacy of control. Particular attention is paid to the propensity to develop hyperglycaemia, ketosis and hypoglycaemia. Ask specifically about the complications of diabetes: nephropathy, sensory and autonomic neuropathy, hypertension, peripheral and coronary arterial disease and retinopathy. The patient looking for these complications is then examined. Look for ongoing infection.

How do you manage the diabetic patient once they are on the ward?

Patients with diabetes often have gastroparesis, and they should fast at least 12 hours before elective surgery. Always try to put the patient first on the list. Patients with diet-controlled diabetes usually just require glucose monitoring. Patients on oral hypoglycaemic agents should have those agents discontinued on the day of surgery. Sulphonyl urea drugs should be withheld at least 1 day before surgery, because of their long half-life. For those on insulin prescribe 5% dextrose with potassium and start sliding scale insulin infusion. Continue the insulin and dextrose infusion until the patient has had a second meal with their normal dose of subcutaneous insulin post-operatively.

What are the potential operative complications in the diabetic patient?

• Infections: diabetics are prone to infection at the surgical site and elsewhere.

• Wound healing: this is impaired in diabetics due in part to microvascular disease.

• Cardiovascular complications: due to macrovascular disease.