Anaesthesia for an Elective Surgery in Diabetes

Diabetes Facts• There is a rising incidence and prevalence of Diabetes. About 50 per cent of people with Diabetes are unaware of their condition.• In a 2017 study of 15 states in India, 11.2 per cent of Indian adults living in large urban centres were found to have Diabetes. The overall prediabetes prevalence was 10.3 per cent.• The most recent estimates are that nearly 73 million people currently have Diabetes in India.• People with chronic high blood sugar levels are associated with long term damage, dysfunction and failure of various organs especially the eyes, kidneys, nerves, heart and blood vessels..A few common surgeries done in people with Diabetes are: Major surgery: • obesity surgery • knee or hip replacement • kidney transplant or other transplant surgery • cardiac bypass surgery Minor surgery: • Eye surgery • Abscess drainage surgery Any major or minor surgery has a risk of complication that can adversely affect the wellbeing of a person. Therefore all people with Diabetes undergoing surgery must be fully counselled and made aware of the safety steps for effective perioperative care. This consists of taking care before, during and post-surgery. When planning for elective surgery, it is important to have an assessment of blood sugar profile, medical history and examination and an assessment of end-organ damage. Before the surgery The physician, surgeon and anaesthetist assess the case in detail before surgery. This would include knowing the duration of the disease, assessment for any Diabetes-related complications or associated conditions that may increase surgical risk, especially autonomic neuropathy (damage to autonomic nerve fibres that supply blood to heart and blood vessels, resulting in abnormalities in heart rate control and vascular dynamics). Here are some points to discuss with your healthcare team before scheduling a surgery: • Before going for any kind of surgery, make sure the attending medical team knows that you have Diabetes and all the Before the surgery The physician, surgeon and anaesthetist assess the case in detail before surgery. medications you take every day • History of snoring, sleep apnoea, short neck • Any loose teeth or artificial dentures • History of smoking, alcohol, tobacco or drug abuse • Any history of taking sleeping pills • Discuss with your doctor and familiarise yourself with the procedure as this will help reduce anxiety • Any alteration in medication before surgery or on the day of surgery (blood thinners, blood pressure medication or thyroid medicines) • Any change in insulin dose or type of insulin • Possibility for scheduling the surgery early in the morning • Need for external insulin or glucose during the operation Till you resume your regular diet, your medicinal routine might be changed. You may get back to a normal diet and medications, once your blood sugar level is under control. Communication is necessary Family members, general physicians, surgeons, anaesthetists and attending nurses need to form a close and well-informed team when a person with Diabetes is undergoing surgery. The team should be fully equipped and each one should know their role clearly for the safety and best results of surgery in a person. Perioperative care is divided into three - preoperative, intraoperative and postoperative. Blood sugar control in perioperative care is important. An HbA 1c (a three-month average of blood sugar level) of: • 10 signifies surgery may need to be postponed In general, a target blood sugar level of 80-130 mgldL for the perioperative period is considered safe. At least 2 weeks of good blood sugar control before surgery is important to stabilise neutrophil function (to boost the immune response against invading pathogens) and prevent postoperative infection. History and examination The following medical history is gathered before planning for surgery: • Assessment of blood sugar control (records of blood sugar levels and HbAlc) • Heart disease: evidence of angina, intermittent claudication and peripheral arterial disease • Examine for postural hypotension (systolic fall of >30 mm Hg on standing) • Neurological disease symptoms such as numbness, pain, paraesthesia, leg ulcers and transient ischaemic attacks • An assessment of heart rate variability (HRV) during deep breathing is a much better way of detecting autonomic neuropathy earlier. • Renal disease symptoms such as excessive urination may reflect high blood sugar in the urine or chronic kidney disease. • Anaemia and hypertension should be detected as possible associated conditions. • The skin should be examined for infection. Pressure areas such as heels and buttocks should be examined for sores. Tests A pre-operative investigation should include blood sugar readings and HbA 1c that are more relevant for long-term control. Blood sugar control must be optimised before surgery if possible. Other tests include: • A complete blood count (haemoglobin level) • ECG (to assess ischaemic and other heart diseases) • 20 Echo, ultrasound of the abdomen (to assess kidney function) • Urine analysis for ketones (poor control), protein (possible renal complications) and bacteriology (for infection • CXR - This is used to screen for pulmonary infections, including tuberculosis • Eye fundus examination Anaesthesia There are two types of anaesthesia administered before any surgery. The choice of anaesthesia varies according to the type of surgery. These are regional or general anaesthesia. In a minor surgery like cataract surgery, regional or local anaesthesia is administered to reduce sensation in a particular area, for example, the eye. In a major surgery like kidney transplantation, general anaesthesia is administered to reduce sensation and movement in the whole body and make it stable. In regional anaesthesia, the patient is awake and has a reduced stress response. Hypoglycaemia is readily detectable as the .patient is awake. Also, postoperative nausea is reduced; chance of aspiration is lowered, rapid return to diet and oral hypoglycaemic medicine and easy postoperative control of Diabetes is achieved with regional anaesthesia.In General anaesthesia, there is a risk of aspiration during the administration of anaesthesia and autonomic neuropathy (it can mask hypoglycaemia and may exacerbate respiratory depression with opioids). This type of anaesthesia protects the pressure areas. Some people might require post-operative ventilation and ICU observation.People with Type 1 Diabetes require insulin administration to manage post-operative blood sugar levels. People with Type 2 Diabetes require multimodal therapy of exercise, diet, medication and insulin.To concludeA person with Diabetes poses many challenges to the anaesthetist, most of which can be anticipated with good preoperative assessment, careful monitoring and an understanding of the relevant pathophysiological features. People with Diabetes are at an increased risk of perioperative complications - cardiac, kidney and neurological manifestations. Regional techniques might reduce some of the associated risks but require monitoring. Also, HbAlc helps measure recent glucose control. One should aim for a stable blood sugar level and avoid hypoglycaemia or hyperglycaemia .Tight glycaemic control can help improve perioperative outcomes.Dr Jayprakash D Galpalli is a Consultant Anaesthesiologist at Pune Anaesthesia & Criti Care Pvt. Ltd. and Chellaram Hospital - DiabetesCare and Multispeciality.

Anaesthesia for an Elective Surgery in Diabetes

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