A T2DM is undergoing a gastric surgery. What is the most appropriate pre-op management?
a. Start him in IV insulin and glucose and K+ just before surgery
b. Stop his oral hypoglycemic on the day of the procedure
c. Continue regular oral hypoglycemic
d. Stop oral hypoglycemic the previous night and start IV insulin with glucose and K+ before surgery
e. Change to short acting oral hypoglycemic
answer: D
Stop long-acting oral hypoglycaemics, e.g. metformin and glibenclamide, 24hr before surgery. Chlorpropamide should ideally be stopped 3d before surgery because of its long action and substituted with a shorteracting drug such as gliclazide. It is no longer recommended in the UK.
Type I (IDDM)
Major procedure
Morning list: Omit morning SC insulin, Start IV insulin/glucose regime at 07:00hr
Afternoon list: Give two-thirds normal morning dose of soluble insulin or one-third of normal dose of pre-mixed insulin before breakfast. Start IV insulin/glucose regime at 11:00hr
When a light diet is tolerated, discontinue IV regime and commence qds SC regime
Minor procedure or good diabetic control
Morning list: Omit morning SC insulin
Afternoon list: Give normal SC insulin with breakfast, Omit midday SC insulin
Ensure IV access. Check blood glucose hourly until patient has eaten. When patient can eat give usual SC insulin.
Type II (NIDDM)
Major procedure or poor diabetic control
Morning list: Start IV insulin/ glucose regime at 07:00hr
Afternoon list: Start IV insulin/glucose at 12:00hr
If patient can eat later that day and control is good, discontinue IV regime and recommence oral hypoglycaemics. If IV > 24hr or control is poor, discontinue IV regime before first meal and commence qds SC regime.
Minor procedure or good diabetic control
Omit tablets on day of procedure. If blood glucose <4mmol/l start 10% glucose at 100ml/hr. Measure blood glucose every 2hr until patient has eaten. Give a meal and tablets as soon as possible after return to ward.
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