Transcript Diabetes mellitus (DM), also known as simply diabetes, is a group of

Diabetes and surgery
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
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%.
• Serious long-term complications include heart
disease,
• stroke,
• kidney failure,
• foot ulcers and
• damage to the eyes.
• 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.
• 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 insulindependent diabetes mellitus" (NIDDM) or
"adult-onset diabetes". The primary cause is
excessive body weight and not enough
exercise.
• 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.
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.
Surgical complications in Diabetic
Patient
• Bacterial infections like abscesses, carbuncles,
chronic balanitis, and diabetic foot.
Emphysematous Cholecystitis,
Emphysematous Pyelonephritis, Necrotising
fasciitis and
Fournier’s gangrene
Fungal infections like candidiasis, Mucormycosis.
• Sexual dysfunctions
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
Wagner’s 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
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.
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
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
• Attempt to convert wet gangrene to a dry one
by repeated dressings and proper antibiotics.
• Once gangrene sets in, decide for amputation.
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.
• 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
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. >200 mg/dl
D.180 mg /dl
2.Long term complication of DM isa.Heart disease
b. renal disease
c. diabetic foot
d. all above
3.Most common cause for leg amputationa.venous ulcer
b.trauma
c.Buerger disease
d. diabetic foot
4.Grade 3 diabetic foot ( wager classification)a.superficial ulcer
b.deep ulcer exposing bone, joint,tendon
c.osteomyelitis
d. gangrene
5. A diabetic pt on oral hypoglycemic agent is planned
for surgery, which one is truea. 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
6. In diabetic patient level of Glycated
haemoglobin (HB A1C) is more than
A. 8.0%
b. 6.5%
c. 4.5%
d. 9.2%