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YOUR PATIENT

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A 7-year-old female with diabetes mellitus (DM) type 1 is booked for an emergency exploratory laparotomy for small bowel obstruction. She has been vomiting for 2 days, and complains of severe abdominal pain. Her diabetes is controlled via a continuous subcutaneous insulin pump. She also has a history of celiac disease and depression. Glucose: 210.

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PREOPERATIVE CONSIDERATIONS

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Patients suffering from type I DM have an absolute absence of insulin production and require an outside source of insulin to control blood glucose. This can be achieved with short-, intermediate-, or long-acting insulin preparations. Patients or parents should be able to inform you as to how much insulin the patient requires and what the correction factor is (how much insulin is required to decrease the blood glucose by 50 mg/dL).

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Patients with type I DM are at risk for hyperglycemia and diabetic ketoacidosis, particularly during times of stress and illness. Note that ketoacidosis may present with symptoms mimicking an acute abdomen. It is important to find out the amount of insulin that the patient requires on a daily basis. Diabetes mellitus has several important complications, including neuropathy (including gastroparesis), nephropathy, vascular disease, and retinopathy.

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ANESTHETIC MANAGEMENT

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  • Continue the patient’s maintenance insulin at the same rate. Patients with an insulin pump may keep the pump if possible, and adjustments will be made with IV insulin.

  • If the pump is discontinued, the patient’s maintenance rate should be given intravenously.

  • Measure the blood glucose at least every hour and make adjustments as needed.

  • Add dextrose to maintenance fluids while you are running insulin, unless the blood glucose is >200 mg/dL.

  • If the patient does not have a pump, an infusion of regular insulin can be started at 0.05 U/kg/h with a maintenance solution of D5% dextrose (D5%) (with NaCl 0.9% or NaCl 0.45%). It is better to have an infusion than to give intermittent boluses of short-acting insulin to keep the blood glucose more constant.

  • In patients managed with a split-mixed combination of fast-acting and intermediate- or long-acting insulin (NPH or ultralente) or insulin glargine (Lantus) who have already taken their morning or daily dose of insulin, remember that the duration of its effect may continue for up to 24 hours.

  • Hypoglycemia is much worse than hyperglycemia, and blood glucose below 80 mg/dL should be treated with D50% (0.5-1 mL/kg).

  • Hyperglycemia (>200 mg/dL) should be treated by administering regular insulin subcutaneously. To determine how much to give, it is useful to know the patient’s correction factor (= 1500/daily insulin dose). One unit of regular insulin will lower blood glucose by correction factor mg/dL.

  • Patients with symptoms of gastroparesis should have a rapid-sequence induction (RSI); in this case, the patient’s condition (small bowel obstruction) requires an RSI regardless of other considerations.

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POSTOPERATIVE CONSIDERATIONS

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Ensure that patients continue to be closely monitored until they ...

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