The volume of surgical care for patients with diabetes is quite large. Approximately every second patient with diabetes during their life undergoes at least one surgical procedure. Diabetes mellitus, especially when well controlled, should not be considered as a contraindication to surgery.
The main condition for any elective surgery is to achieve diabetes compensation. Even small surgical interventions (removal of atheroma, ingrown nail, opening of an abscess, etc.), which can be performed on an outpatient basis in patients without diabetes, must be carried out in patients with diabetes in a surgical hospital. At the same time, if the patient has controlled diabetes while taking tablets, there is no strict need for insulin during surgical interventions of such a plan. Patients receiving biguanides, in order to avoid acidosis and the development of lactic acidosis, should be moved to insulin with the cancellation of biguanides.
The main condition for any elective surgery is to achieve diabetes compensation
Before large abdominal planned operations, the patient, regardless of prior therapy, needs to be transferred to insulin according to the usual sliding scale. The patient is recommended 3-4 times (with severe labile forms of diabetes – 5 times) the introduction of simple insulin under the control of blood sugar and glycosuria during the day. The use of long-acting drugs before surgery is impractical (you can allow evening injection of insulin of medium duration), as this complicates the correction of insulin. The diet should take into account the characteristics of the disease, for which the patient is operated on. To prevent acidosis, especially in the period after surgery, fats should be limited in the diet, in the absence of contraindications, an abundant alkaline drink is prescribed.
The regimen of insulin administration and nutrition in patients who have to undergo a small operation under local anesthesia, not interfering with food intake, cannot be changed. After administration of insulin and breakfast, the patient is taken to the operating room, and after 1.5-2 hours he is given a second breakfast.
Before large abdominal planned operations, the patient needs to be transferred to insulin according to the usual sliding scale. The regimen of insulin administration and nutrition in patients who have to undergo a small operation under local anesthesia, not interfering with food intake, cannot be changed.
Patients who are undergoing abdominal surgery or any operation that excludes eating, as well as patients operated on under general anesthesia, should be given about half their morning dose of insulin before surgery. 30 minutes after the injection of insulin, 20 to 40 ml of a 40% glucose solution is administered intravenously, followed by a continuous administration of a 5% glucose solution. Further administration of glucose and insulin is corrected by the level of glycemia, determined every 2 hours. Metabolic stress associated with general anesthesia and surgical intervention, usually leads to an increase in the need for insulin. The time of administration and dose of insulin is controlled by blood sugar and urine. Usually, until the patient has completely stabilized, simple insulin is administered 2 to 6 times or more per day.
Stopping insulin in the postoperative period in a patient who previously received insulin is unacceptable. This threatens the development of acidosis. In cases of maintaining normal levels of glycemia during the day (very rarely!), Patients are given fractional doses of insulin (6-8 units 2-3 times a day) under the guise of a 5% glucose solution. In the postoperative period, patients are required to check urine daily (or several daily portions) for acetone.
Stopping insulin in the postoperative period in a patient who previously received insulin is unacceptable!
After 3-6 days (sometimes more), provided that the general condition is stabilized and diabetes compensation is maintained, the patient can be transferred to his usual regimen of insulin administration. When it becomes possible to eat after the postoperative period, a mechanically and chemically sparing diet is prescribed and treatment with insulin is continued. It is possible to stop insulin and transfer the patient to sulfonylurea meds 3-4 weeks after the operation, provided that the wound is completely healed, there are no inflammatory phenomena, diabetes compensation is preserved, and there are no contraindications for taking sulfonamides.
With urgent, urgent surgical interventions, it is difficult to give a specific scheme for the administration of insulin. It is set purely individually according to the initial level of sugar in the blood and urine, which is subsequently monitored every 1-2 hours, and also taking into account the daily dose of insulin received by the patient before surgery and the patient’s sensitivity to insulin for the first time diagnosed with diabetes.
Every patient undergoing urgent surgery should be tested for blood sugar!
When decompensating diabetes mellitus with signs of ketoacidosis, the patient should be operated on against the background of measures aimed at eliminating ketoacidosis, with fractional administration of simple insulin under the control of glycemia. If the operation can be postponed, ketoacidosis must first be eliminated. Patients who received prolonged insulin on the eve of emergency surgery may require (under the control of glycemia!) An additional correction with simple insulin.
Diabetic coma is a contraindication for surgery. First, urgent measures are taken to remove the patient from a coma, and only after that it is possible to carry out surgery.