DM

Question 1

65-year-old with type II DM, on oral medications. Presented with perianal abscess and went for I&D

What are the types of DM and describe the pathogenesis of each?

What is the function of insulin and what are other hormones affecting blood glucose level?

Answer 1

The vast majority of cases of diabetes fall into one of two broad classes:

• Type 1 diabetes (T1DM): is characterized by an absolute deficiency of insulin secretion caused by pancreatic beta cell destruction, usually resulting from an autoimmune attack. Type 1 diabetes accounts for approximately 10% of all cases.

• Type 2 diabetes (T2DM): is caused by a combination of peripheral resistance to insulin action and an inadequate compensatory response of insulin secretion by the pancreatic beta cells (relative insulin deficiency). Approximately 80% to 90% of patients have type 2 diabetes.

The principal metabolic function of insulin is to increase the rate of glucose transport into certain cells in the body

Carbohydrates:
• Increases the uptake of glucose into various tissues
• Stimulates glycogenesis in many tissues, but especially the liver
• Stimulates hepatic generation of glucose-6-phosphate from glucose

Proteins:
• Enhances the uptake of amino acids into peripheral tissues
• Stimulates protein synthesis –for this reason, insulin can be regarded as one of the growth hormones

Fats:
• Stimulates lipid uptake into cells
• Enhances oxidation of lipids once inside cells
• Also causes fat deposition by stimulating lipogenesis in adipocytes and in the liver

Question 2

Other hormones affecting blood glucose level

Precautions for diabetic patient going for surgery? How to prevent intraoperative hypoglycemia? (In details)

what type of insulin you going to give in variable insulin infusion (previously called sliding scale

Immediate and late post-operative complications?

If this patient is going for surgery what lab investigation you will do to prevent immediate complications?

Post-operatively, who you will involve in care of this patient?

What do you think this patient might need if his DM not well controlled on oral medications?

Answer 2

All of them increase blood glucose level
Glucagon
Catacholamines: epinephrine and norepinephrine
Glucocorticoids: most important being cortisol
• Somatotrophin: a pituitary hormone

• Patients with diabetes must be prioritized in the operating list
- First do invx: you should mention ABG and Potassium level
• Routine overnight admission is not necessary
Also mention:
Starvation time should be no more than one missed meal
If oral medication is controlled just omitting the morning dose.
If he is not controlled covert him to variable insulin infusion therapy
• Analgesia and anti-emetics should be used to enable early return to diet and usual insulin regime
• Insulin infusions should only be used if a patient is expected to miss more than one meal
• 0.45% sodium chloride with 5% glucose and 0.15% or 0.3% KCI is the recommended IV fluid
Capillary blood glucose should be measure hourly during and after the any surgical procedure
The WHO surgical safety checklist should identify all diabetic patients
The target blood glucose should be 6-10 mmol/ L (acceptable range 4-12 mmol/ L).

Short acting.

Immediate:
• Hyper or hypoglycemia
• Dehydration with electrolytes imbalances
• Hyperglycemic hyperosmolar syndrome
• DKA
Late:
• Infection
• Sepsis
• Impaired wound healing

• Blood glucose level
  Serum Potassium level.
• ABG

Endocrinologist + his GP + his family

Conversion to insulin therapy Variable insulin infusion.

Question 3

What will you do in case surgery of diabetic patient is delayed for 4 hours

How will you manage this patient intraoperatively

Investigations to confirm diagnosis of DM

Answer 3

I’ll monitor capillary glucose hourly. If glucose is high, I’ll start a variable insulin infusion with dextrose and potassium until surgery.

In OR I will continue variable rate IV insulin infusion with dextrose and potassium, monitor glucose hourly, maintain fluids, and keep strict aseptic precautions. I’ll also monitor ECG, BP, SpO₂, and temperature, and be careful about aspiration risk, silent ischemia, and infection risk

Oral glucose tolerance test, Fasting blood glucose, Hb A1C level