Can Diabetes make surgery more complicated? Subimol Abhilash Murali offers tips to counter the cyclic impact Diabetes and surgery have on each other.
Diabetes and surgery
People with longstanding Diabetes get used to factoring their condition into every decision they make. This could include diet, daily routine, working hours, travel plans and almost anything and everything in between. So when it comes to an important medical procedure such as surgery, your Diabetes is bound to provide some additional homework for you and your medical team. Diabetes may be the very reason you need that surgery in the first place – as a result of a plethora of direct and indirect complications.
Here, we take a look at how Diabetes and various kinds of surgeries affect each other. We will also take a look at a particular kind of surgery that may perhaps provide hope for a cure for Diabetes!
A look at the basics
Just because you have Diabetes does not mean you should hesitate to get that troublesome hernia removed. Before going for any kind of surgery, make sure the attending medical team knows that you have Diabetes and all the medications you take every day. The physician, surgeon and anaesthetist can assess the case in detail before surgery. This would include knowing the duration of the disease, checking for any Diabetes-related complication or any associated conditions that may increase surgical risk, especially the presence of cardiac autonomic neuropathy (damage to the autonomic nerve fibres that supply blood to the heart and blood vessels, resulting in abnormalities in heart rate control and vascular dynamics).
Your medical team will decide the best course of action for you about how:
- long you need to be admitted and monitored before the surgery
- your medication and insulin doses may need to be modified
Good blood sugar control before surgery would improve recovery and reduce the overall disease management costs. In general, complications from surgical wounds are higher and healing is impaired when blood sugar levels are not well managed.
The trauma associated with surgery results in increased production of stress hormones such as cortisol (a steroid hormone that regulates metabolism and the immune response) and catecholamines (hormones released into your blood when you’re physically or emotionally stressed) which reduce insulin sensitivity.
Discuss with your doctor and familiarise yourself with the procedure as this will help reduce anxiety. As far as possible, you should be closely monitored before elective surgery. Some points to discuss with your medical team are:
- Any alteration in medication before surgery or on the day of surgery (blood thinners/ thyroid medicines/ blood pressure medicines, etc)
- Any changes in insulin dose or type of insulin
- Would it be possible to schedule the surgery early in the morning?
- Will you need any external insulin or glucose during the operation?
- Till you resume your regular diet, your medicinal routine might be changed.
- You may get back to your normal diet and medication, once your blood sugar level is under control.
- Establishment of certain glycaemic target levels before surgery
Remember, this information is to help you understand and know what to expect – your physician is the best person to prescribe the proper course of action for you. Follow their advice very carefully. With the right kind of care and advice, your Diabetes should not affect the safety and outcome of the surgery.
What about surgery for, say, transplanting a donor kidney in place of a damaged kidney because of Diabetes? Poorly controlled Diabetes may lead to complications that, beyond a point, only a surgeon can address.
Some common examples of major surgeries are:
- Eye surgery
- Cardiac surgery
- Organ transplant surgery
- Foot surgery/amputation
- Bariatric surgery
Every minor or major surgery has a risk of complication that can adversely affect your well-being. Therefore, all people with Diabetes undergoing surgery must be fully counselled and made aware of safe and effective perioperative care. This consists of care taken before, during and post-surgery. People with Diabetes are however more at risk and these high risks revolve around three major concerns:
- Higher risk of infections
Tissues, in Diabetes, are at risk of infection because the raised blood sugar acts as a good ‘sugary’ place for all types of bacteria to reside and multiply. The relatively lower blood supply in many long-standing diabetic tissues reduces self-protection against these bugs and so resistance to infection is lowered (known as ‘low immune status’).
- Higher risk of bleeding (haemorrhages) and loss of blood supply (called ischemic events)
The small blood vessels in people with Diabetes are often unhealthy (a condition referred to as ‘microangiopathy’) and this is largely due to uncontrolled sugar and tobacco use. It is also to some extent not related to sugar levels/tobacco and is a part of the many years of the Diabetes process itself. Due to this problem, any surgery of a person with Diabetes can become complicated with higher bleeding events during or after surgery and also higher chance of tissue damage due to loss of blood supply to a part or whole of tissue due to closure (called occlusion) of one or more abnormal blood vessel branches. This problem is worsened in people whose blood pressure is uncontrolled or in those who are required to take blood thinners.
- Higher risks of systemic complications
Due to other organ damage especially due to microangiopathy, an individual with Diabetes is always at a risk of minor or major complications in other organs of the body while undergoing surgery. These include, but are not limited to, problems such as heart attack, stroke, breathlessness or heart failure, bedsores, kidney failure or urinary tract infections etc.
Important counselling points
The following are important points on what a person with Diabetes should be counselled on and made aware during the perioperative period. This will help avoid or minimise the above-known risks related to any surgery.
Family members, nurse, general or specialist physician of the patient and the doctor need to form a close well-informed team when an individual with Diabetes is to undergo surgery. Ensure that communication lines are open and clear, all phone numbers are at the bedside of the person and with a family member and the ‘team’ is fully geared up and knows their role clearly for the safety and best results of surgery in their patient. Just like ‘know your customer’, the team should be fully aware of the medical condition of the person.
Blood sugar control
Blood sugar control in the perioperative period is important. Perioperative blood sugar control can be divided into preoperative, intraoperative and postoperative management.
- HbA1c < 7.5 per cent signifies fitness for surgery
- HbA1c 7.5 to 11 per cent signifies a need for blood sugar control
- HbA1c >11 per cent signifies that surgery may need to be postponed
In general, a target glucose range of 80 to 180 mg/dL for the perioperative period is considered acceptable. At least two weeks of good glycaemic control before surgery is important to stabilise neutrophil function (to boost the immune response against invading pathogens) and prevent post-operative infection.
Treatment of all infections
Ensure that there are no infection points, anywhere, currently in the body. These include any skin boils, infected facial pimples, nail infections, lid and lacrimal sac infections, any partly healed abscess, urinary or dental or nasal infections, sore throat etc. All infections should be thoroughly treated before going in for any surgery.
Maintain strict hygiene including hair washing and bathing, shaving/beard trimming, nail trimming, face washing, frequent hand washing, etc on day of surgery both for the patient and the attending family member.
Before booking the date for any planned surgery, a person with Diabetes must discuss the ‘timing’ and ‘duration’ of surgery with both – the respective surgeon and the Diabetes care doctor. This is a very important aspect, sometimes in case of a complication, which could have been prevented or at least anticipated! Blood pressure, blood sugars, heart and lung conditions, kidney and urinary/prostate conditions, body electrolytes and bleeding/clotting condition all need to be evaluated before surgery.
Common aspects, to be decided as a team, based on the individual and some established guidelines include:
- Should blood thinners be stopped and for how long?
- Can aspirin be continued?
- What would be safe sugar and blood pressure levels for the given surgery?
- What pain killers to avoid?
- What supplements/herbal medicines to avoid?
- How to adjust dialysis schedule to avoid conflict with the surgery day?
- What other drugs to avoid and what type of perioperative cardiac monitoring will be required if a person has a heart problem?
- All these aspects should be well planned so that during the perioperative period one is ready for safe surgery.
What routine medicines should be taken on the day of surgery, the night before and immediately after surgery? Most people with Diabetes are on multiple drugs. In general, they should take their blood pressure medicine on the day of surgery. Usually, people need to take all medicines for blood pressure, asthma, seizure (if epileptic) etc. However, whether the surgery is under general or local anaesthesia and the type of surgery the person has to undergo will depend on the answers to the above questions.
Clear information of what other medications should be taken or not taken on the day of surgery should be discussed and taken down in writing from the doctor in detail. All medication, once admitted in the hospital for surgery, must only be administered by health professionals.
People with Diabetes should always bring their recent drug chart and reports of all tests done before surgery (like ECG/X-ray/consultations with cardiologist etc) to the hospital along with the list of prescribed medications that are used daily or in an emergency.
It is the responsibility of the person undergoing surgery and the attendant to ensure this point. Running around for this information and drugs wastes a lot of time and is annoying for all concerned in the team. Even if the hospital staff or doctor sometime says ‘no need to get this’ it is wise planning to have these ready in the hospital in case needed at any point of time.
People with Diabetes while awaiting surgery might land into problems such as dehydration, low blood pressure, hypoglycaemia (low sugar feeling) because they may eat/drink less or maybe in the fasting state on the day of surgery. When people undergoing surgery are advised fasting or diet restrictions, the person undergoing surgery and attendant should be vigilant about remaining hydrated (dehydration increases the chances of strokes and some infections) and preventing low blood pressure or sugar.
They should report immediately to the nurse/operation theatre in-charge or doctor if they experience symptoms like shivering, weakness, lethargy, sweating, dizziness, slowing of speech etc.
Most importantly people with Diabetes should remain positive about good outcomes after surgery as the majority of people with Diabetes do very well after surgery and only few experience complications, the number of which is low overall. If planning is thorough, the team members are on board and alert, all preparations will be in place to prevent and handle any untoward events. These will ensure in most cases gratifying outcomes and great surgical experience. Most of the concepts presented here are also applicable to many other surgical scenarios as well as for people who do not have Diabetes.
Ms Subimol Abhilash Murali is Sister-in-charge of an operation theatre.