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Diabetes management in surgery 

Diabetes management in surgery
Chapter:
Diabetes management in surgery
Author(s):

Andrew P. Hall

and Melanie J. Davies

DOI:
10.1093/med/9780199235292.003.1495
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date: 16 November 2019

Diabetes mellitus is a common condition in the general population, and particularly so among hospital inpatients. Complications associated with diabetes mellitus further increase its incidence in surgical patients, particularly those requiring vascular, renal, or ophthalmic procedures.

Patients with diabetes have a higher rate of morbidity and mortality associated with surgery. This includes cardiovascular and renal complications, infection, and impaired wound healing. The process of surgery, a controlled form of trauma, provokes a metabolic response due to the release of cytokines and stress-associated hormones. These agents promote a catabolic state that includes increased insulin resistance. The resulting hyperglycaemia leads to overflow of substrates in the mitochondria and the generation of excess free oxygen radicals, which can be toxic to the cell. It should, therefore, be possible to reduce these effects by avoiding or attenuating the stress response and/or counteracting its metabolic effects. The stress response is proportional to the degree of tissue trauma. Insulin administration and normoglycaemia have been shown to reverse catabolic changes and improve wound healing and skin grafting, and also to reduce the incidence of infective complications.

Additionally, the stress response may be, in part, attenuated by the choice of anaesthetic technique. Neuraxial (spinal and epidural local anaesthetic) analgesia can reduce sympathetic nervous system tone and adrenal output. Additionally, much ophthalmic surgery is now performed with local anaesthesia techniques. Such approaches avoid the more prolonged starvation and cardiorespiratory risks associated with general anaesthesia.

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