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Special treatment of metabolic disorders
The patient is transferred to simple insulin, administered four times. With a duration of action of the drug up to 6 hours, it is possible to smoothly regulate the metabolism for 24 hours and it is easy to eliminate metabolic fluctuations within the framework of operational stress.
The amount of insulin is distributed mainly as follows:
The highest dose is in the morning; the average dose is in the evening; smaller dose - at lunch; the smallest dose (mostly 4–8 U, in exceptional cases, 12 U) in the night between 24 and 1 h (without additional food intake!).
in the morning 16 U
at lunch 8U
in the evening 12 U
at night 4 U
The number of insulin units is determined by the dosage of the applied insulin depot, the sugar content in the blood and the amount of sugar excreted in the urine, which is determined in portions of urine collected in the intervals between insulin injections, and from evening to morning only one portion is collected. The insulin dose must be selected according to the amount of sugar lost with urine, since the renal threshold for sugars may be different. Also, it was not confirmed that the previously applied dose of depot insulin should be 2/3 of the amount of insulin required. The basis for accurate determination of the dose of insulin is only the daily glycemic profile of the blood (determination with a two-hour interval). Fluctuations require correction.
Tactics for minor interventions (opening an abscess, etc.)
Stable and well compensated metabolism
A patient with diabetes, compensated by a diet, is sent to the operating room on an empty stomach and does not need any special appointments with uncomplicated course. However, monitoring the general condition of the next day is necessary.
A patient with diabetes who is treated with oral antidiabetic drugs does not take his pills in the morning, goes to the operating room on an empty stomach and continues his usual medication in the afternoon.
A patient receiving insulin is not given an injection in the morning.
At lunch after surgery, the patient is administered / 3 of his usually morning dose of insulin (Daweke). With further abstinence from food, the patient is given a slightly sweetened tea, but insulin is not administered. In no case, with outpatient interventions, without knowing anything about the state of metabolism, you can invite the patient to the operating room on an empty stomach after administering the morning dose of insulin! Required to carefully collect history.
Consultation with a therapist is recommended, since it is with a labile metabolism that small doses of insulin may be required. In case of doubt, an inpatient examination is necessary.
Metabolism correction during surgery
Patients with diabetes, compensated by the diet, in case of the need to deliver energy and fluids on the following days, are not assigned glucose solutions, but only fructose, sorbitol or xylitol.
Patients with diabetes, well compensated by sulfonamides, on the day of surgery, at the beginning of anesthesia, 1.0 g of tolbutamide is administered in 500 ml of fructose 50 infusion solution for 30–60 minutes. During the day, at least 75 g of carbohydrates are prescribed at least another operation [Bauch et al., 1974] (Fahndrich et al., Schmitt, Daweke). Tolbutamide is dissolved only in neutral solutions (infusion solutions of fructose or glucose, electrolyte infusion solution 153), since otherwise a precipitate may fall out (Fahdrich et al.). With a sharper postoperative increase in blood sugar levels, a second infusion of tolbutamide is administered in the afternoon. If necessary, in these hours you can enter insulin.
In this regard, one should indicate the danger of hypoglycemia due to changes in the pharmacokinetics of sulfonylurea derivatives caused by drug interference, as well as hepatic and renal insufficiency (Berger, Spring, Constam, SteingaB, Werner; Tables 27 and 28).
| Table 28. The effect of other drugs on the pharmacokinetics of sulfonylurea derivatives __________________________________________ |
| Absorption || Improved by sodium bicarbonate |
| Distribution || They are displaced from protein bonds by sulfonamides, salicylates, phenylbugazone |
| Metabolism || Cleavage in the liver is inhibited by phenylbutazone, chloramphenicol, coumarin derivatives, sulfaphenozole, ethanol |
| Elimination |
| Inhibited by probenzide, salicylates, phenylbutazone |
Patients receiving insulin, before lunch the day before the operation is administered the usual dose of insulin. In the evening and at night the patient receives half the dose of insulin and some sweetened tea. During the operation, half of the insulin dose is administered, and with a higher insulin dosage - 2/3 daily dose (Forsham, Jackson). Insulin is administered subcutaneously or intravenously as part of an infusion solution. The loss of insulin in the infusion system, which has practical significance, is observed with very long exposure, a large ratio of the surface of the volume of the infusion solution and a small concentration of insulin. Adding plasma protein or human albumin (1 or 2 mg / dL) significantly prevents adsorption losses (Suess, Froesch). As a donor of energy and liquid, as a rule, an infusion solution of fructose 50 is used, and with large amounts of insulin, an infusion solution of glucose 50 is also administered.
Short-term infusion of plasma-substituting solutions on a polysaccharide basis to combat shock or to improve microcirculation does not have a significant effect on metabolism (Hierholzer et al.). However, with a polarimetric determination, there may be false results of high sugar content in the urine due to their renal excretion (see Table 26). After the introduction of dextran, it is impossible to accurately determine the blood sugar by the original orthotoluidine method, for this it is necessary to modify the study by means of dextrogens.
Without a doubt, canned blood can be used, as well as electrolyte solutions without glucose.
Blood sugar is determined by any tactics of management of a patient with diabetes before surgery, during long operations and after their termination. If necessary, it is determined frequently. Urine is examined for sugar and ketone bodies. A patient with diabetes should be operated as far as possible long before lunch and at the beginning of the week (better laboratory control!).
The immediate danger during surgery is not hyperglycemia, but above all unrecognized hypoglycemia.
You should think about hypoglycemia during slow awakening after anesthesia or with sweating. By a corresponding change in the dose of insulin or the introduction of carbohydrates, you can quickly eliminate this metabolic disorder. However, with the tactics described above, these complications almost never arise.
Maintaining a patient with diabetes in the postoperative period
Even in patients with diabetes, compensated by diet, it is necessary to control the metabolism after the operation by examining blood sugar and urine to prevent decompensation (especially in case of complications: renal failure, bleeding, etc.).
A patient receiving sulfonylurea drugs during surgery is prescribed the same treatment after surgery as on the day of surgery. If possible, oral food intake is transferred to treatment with sulfonylurea derivatives, administered orally according to the same scheme as before the operation.
In patients receiving insulin, the dosage of the drug in the future is determined by the results of the study of blood sugar and in accordance with the required dose, determined before the operation. After surgery, this dose may be significantly less.
The required insulin dosage on postoperative days is almost half or 2/3 of the previous insulin dose. If the operated patient in the evening after the operation can again take the full amount of food, then an insulin dose is required, which he received before the operation. As nutrition is restored in a natural way, it gradually and smoothly proceeds to the final dosage of insulin.
For several days after the operation, solutions of glucose, amino acids, fructose, sorbitol or xylitol are used for parenteral nutrition under the control of blood sugar. Fat emulsions due to ketosis tendency and the frequency of primary and secondary hyperlipoproteinemia in diabetes should be used with greater caution than in patients with normal metabolism. The introduction of alcohol should be avoided.
With postoperative complications, for example, with pneumonia, the formation of abscesses, renal failure, hyperglycemia and ketosis easily develop. The main principles of coma therapy are used in their treatment. Complications are treated according to the usual principles.
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Special treatment of metabolic disorders
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