Module 10

DM during surgery, sick-days and

Ramadan
Prevention of DM
 Objective

• To enumerate the basic principles of management of diabetes mellitus

during surgery.
• To highlight the special care during days of sickness.
• To focus on the special aspects of Ramadan fasting.
• To discuss on prevention of diabetes mellitus.
 Surgery and DM
• Surgery in diabetic persons has associations with increased risk of per-operative and post-operative complications
compared to those in non-diabetic persons.
• This is due to the involvement of their vital organs including the autonomic nervous system in the course of the disease.
With optimal care, a surgery can be safe in diabetics.
• Necessary surgical procedures should not be avoided due to diabetes.

Poor metabolic control results in acute metabolic complications by the surgical

Some Key

diabetic persons
surgery of
points regarding

stress which may endanger life.

The infection, if develops, tends to become virulent; it further worsens the
metabolic stability, thus creates a vicious cycle.
Hyperglycemia itself leads to impaired wound healing, deficient formation of
granulation tissue and thereby poor tensile strength of collagen. The fibroblast
formation takes longer time and there is a deficient capillary growth into the
wound. The chemotactic, phagocytic and bactericidal activity of the neutrophil is
deficient. There is impaired humoral host defense mechanism and abnormal
complement function.
Aim should be to have optimal control of diabetes in all diabetics undergoing
surgery. This may not be always feasible, especially in an emergency situation.
 Factors to be considered
during planning surgery

1. Type of diabetes mellitus

2. Treatment - diet, oral anti-diabetic drugs, insulin etc.
3. Metabolic status
4. Vascular status - mainly cardiac, also renal and cerebral
5. Neurological status - specially of autonomic nervous system
6. Type of surgery - Emergency or elective; minor or major procedure
7. Type of anesthesia
8. Post-operative oral intake
 General principles of management
The general principles for safe surgery in diabetic persons is to follow some stepwise actions.
There are 5 steps of actions.

Steps Actions
1. Pre operative assessment
2. Actions of Day prior to Surgery
3. Actions of Day of Surgery
4. Actions of During operation
5. Post-operative care
 General principles of management
( Step 1 & 2)
Step 1. Pre-operative assessment for Surgery for person with DM
1. Pre-operative assessment must be done in close consultation with the physician, surgeon and
anesthetist
2. It should include assessment of any diabetic complications or associated conditions, which may
increase surgical risk, e.g. cardiac autonomic neuropathy.

Step 2. Actions of Day prior to Surgery for person with DM

1. Long acting secretagogues and biguanides should be changed prior to surgery.
2. For major surgeries, the patient may be kept nil per oral (NPO) over-night prior to surgery; in
patients with gastroparesis, the duration of NPO should be around 10-12 hours.
 General principles of management
( Step 3)

Step 3. Actions of Day of Surgery for person with DM

Anti-diabetic medications are omitted on the morning of the operation.
Surgery should be scheduled as early as possible in the morning.
In all major surgeries glucose-insulin infusion should be started. The unit of insulin to be added to 5 or
10% dextrose or dextrose saline needs to be individualized and adjusted as per the results of the
glucometer readings. Blood glucose should be monitored 1 to 2 hourly; it should be in the range of
6.0-11.0 mmol/L. Glucose-insulin-potassium infusion may be considered according to situations.
During minor surgery glucose-insulin infusion may sometimes be required in uncontrolled diabetes,
but not in stable state.
 General principles of management
( Step 4)

Step 4 Actions of During operation for person with DM

The choice of the anaesthetic agent is best left to the anaesthetist; there is no preferred
1. choice of anaesthetic agent for diabetics
2. Cardiovascular status should be closely monitored during surgery.
The glucose-insulin administration is continued where it is required; it is guided by blood
3. glucose monitoring.
 General principles of management
( Step 5)

Step 5 Post-operative care for person with DM

The glucose-insulin administration is continued (where required) till the patient is able to
1. take oral, food.
At this time, if the blood glucose is not under fair control, short acting insulin can be given in
2. small doses.
Once patient is back on his routine diet and is stable, he can be managed with the regimen
3. he was on prior to surgery
 Specific strategies
of Surgery with DM

Four specific strategies

1. For minor surgery in well controlled DM
2. For major surgery (requiring over-night NPO)
3. For poorly controlled DM
4. For emergency surgery
 Specific strategies
of Surgery with DM
Strategies for minor surgery in well controlled DM
Patient on short acting secretagogues and/or insulin should omit breakfast and the morning dose.
1.
The drug(s) should be restarted once patient is back on routine diet after operation.
Patient on long acting secretagogues should replace it with shorter acting secretagogues at least 5
2.
days prior to surgery.
3. Per-operative glucose-insulin drip is usually avoided.
 Specific strategies
of Surgery with DM

For major surgery (requiring over-night NPO)

1. Diabetes should be controlled by insulin
2. Per-operative glucose-insulin drip is essential.
In the post-operative period, once diet is resumed, patients usually do better with short
3.
acting insulin therapy.
4. Restarting of the patent's previous regimen can be done once the patient is fully stable
 Specific strategies
of Surgery with DM

For poorly controlled DM

1. Insulin is used to control diabetes in all types of operation
2. Hospitalization of the patient at least 3 days before operation.
3. Short acting insulin is preferred; but this also depends on type of DM and operation etc.
4. Per-operative glucose-insulin drip is required, especially in major surgery.
 Specific strategies
of Surgery with DM
For emergency surgery
1. Patient is hospitalized.
2. Insulin infusion is started and frequent monitoring of blood glucose is done
3. Electrolytes, acid base status and urinary ketone levels are checked.
4. If feasible surgery is delayed till blood glucose comes below 20 mmol/L and ketonuria disappears.
5. If delaying is not possible, operation with intensive management of diabetic sate is to be done.
6. Other managements according to general principles of emergency surgery should be followed.
 DM management on Sick days
[Sickness like fever, vomiting &diarrhea]

Frequent tests for blood glucose & Sufficient intake is necessary to The anti-diabetic agents should
ketone in urine maintain fluid balance. not be stopped altogether;
Dose of insulin / secretaguges may
If the blood glucose is low, need to be reduced.
sweetened fluids, e.g. fruit juice is Longer acting secretaguges may
to be given to avoid hypoglycaemia. need to be replaced by shorter
If blood glucose is elevated, low acting ones or insulin.
calorie soft drinks, soup or broth In case of vomiting or diarrhoea
may be given. metformin/ alfa-glucosidase
inhibitors is withdrawn temporarily
 Some key points on Sick days’ management

1. The principles of sick days are to be

followed until the blood glucose is < 12 4. Hospitalization is considered if:
mmol/L and ketone diminishes or  Vomiting or diarrhoea persists for longer than 6
disappears. hours
 Sick for 2 days and not getting better.
2. In situations with fever, the infective  Moderate ketonuria persists despite treatment.
Blood glucose remains above 14 mmol/L.
focus should be treated. 
 Moderate ketonuria persists despite treatment.
3. Treatment for vomiting/diarrhoea may  Very young individual.
 Abdominal pain.
also be required.  Hyperventilation.
 Co-existing serious diseases
 Ramadan fasting and diabetes mellitus

• More than 50 million people with diabetes

worldwide fast during Ramadan. During fasting a The harmful consequences associated with fasting
Muslim must abstain from eating, drinking, use of are:
oral medications, parenteral rehydrating or energy • Hypoglycemia (7.5 fold increase in severe
providing fluid or medication, and smoking from hypoglycemia in T2DM),
predawn (Sahur/sehri) to sunset (Ifter). However, • Hyperglycemia (5 fold increase in severe
there are no restrictions on food or fluid from ifter hyperglycemia in T2DM),
to sehri. • Ketoacidosis,
• Dehydration and
• Diabetic patients are at risk of harmful • Thrombosis.
consequences due to the changes in pattern and
amount of food and fluid intake during Ramadan.

Severity of the risk in an individual i.e. categorization depends on factors namely diabetic
control, treatment regimen and co-existing disease.
 Categories of risk in DM for Ramadan
Risk categories Features
 Severe hypoglycemia within the last 3 months prior to Ramadan
 Patient with history of recurrent hypoglycemia
 Patient with hypoglycemia unawareness
 Patient with sustained poor glycemic control
 Ketosis within the last 3 months prior to Ramadan
Very high risk group  Type 1 DM
 Acute illness
 Hyperosmolar hyperglycemic coma within the last 3 months
 Patients who performs intense physical labour
 Pregnancy
 Patient on dialysis
 Patient with moderate hyperglycemia (average blood glucose between 150 and 300 mg/dl, HbA1c 7.5-9.0%)
 Patients with renal insufficiency
 Patients with advanced macrovascular complications
High risk group  People living alone who are treated with insulin or sulphonylureas
 Patients with comorbid conditions that presents additional risk factors.
 Old age with ill health
 Drugs that may affect mentation
Moderate risk group  Well controlled patients treated with short acting secretagogues such as repaglinide or nateglinide

Low risk group  Well-controlled patients treated with diet alone, metformin or a thiazolidinedione who are otherwise healthy.

N.B: *As per ADA consensus.

 Diabetic people belonging low & moderate risk group can perform ramadan fasting and they have to follow general measures of management.
 People in very high risk group should observe the exemption for them regarding fasting.
 People in high risk group should consult a diabetologist to have an individual assessment before taking desicion regarding fasting.
 Management of diabetes during Ramadan

Management of diabetes during fasting should consist of pre-Ramadan medical assessment and educational
counseling. Persons eligible for fasting needs appropriate modification in diet and drugs, and monitoring of
blood glucose on regular basis,

General considerations
Frequent monitoring of glycemic status: Two important times are 2 hours after sehri and 1 hour prior to ifter.
Testing at other times may also be done.
Nutrition: In terms of calorie and composition, diet should remain same healthy and balanced as before Ramadan.
Ingestion of large amount of foods rich in carbohydrate and fats during ifter should be avoided. A complex
carbohydrate that is slow in digestion and absorption is good choice for sehri, while food with more simple
carbohydrate may be taken during ifter. Sehri (pre-dawn meal) should be taken as late as possible.
Exercise: Normal level of activity is recommended. Excessive physical activities may lead to hypoglycemia.
Tarawih prayer can be considered as part of daily exercise program. Exercise between ifter and dinner may be
undertaken.
Breaking the fasting: If blood sugar goes <3.3 mmol/L (60 mg/dl) at any time, or <3.9 mmol/L (70 mg/dl) during
first few hours of sehri, or > 16.7 mmol/L (300 mg/dl), and on sick days.
Medical assessment: Glycemic status, BP and lipid profile are to be stabilized before Ramadan.
Blood glucose must be checked after first few days of fasting to readjust the doses of the medications.
 Management of diabetes during Ramadan
Specific measures

Type2 DM
 Patients on diet control only - risk during fasting is low.
 Patients on oral agents:
 Risk of fasting hypoglycemia is low if on insulin sensitizers or DPP-4 inhibitors or GLP-1 agonists; but risk increases when secretagogues (specially longer
acting) are used.
 Biguanide- needs some dose adjustment.
 Glitazone, DPP-4 inhibitors and GLP-1 agonists, alpha glucosides inhibitors - need no dose change.
 Secretagogues-glimepiride/glicazide-MR/glinides are preferred preparations; sulphonyl- ureas need some dose adjustment; glinides need no dose change.
 Patients on insulin - dose readjustment is to be made according to the type of insulin.
 Patients on once-daily-drug-regimen (OAD or insulin) - the usual dose of antidiabetic agent can be taken at sun-set; sometimes the dose may need to be
reduced.
 Patients on twice-daily-drug-regimen (OAD or insulin) -the usual morning dose of anti-diabetic agent is taken at sun-set; the evening dose is reduced to 50%
and taken at dawn.
 Patients on thrice-daily-drug-regimen (OAD or insulin):
o The total dose of metformin is divided into two-thirds to be taken at sun set, and one-third at dawn.
o In case of rapid acting insulin or glinides the usual dose can be taken with meals.
o Short acting insulin is to be taken twice daily with larger share at sun-set.
 Patients on basal -bolus (4 times) insulin regimen - long acting insulin may be taken at sunset in reduced dose with rapid acting ones 2-3 times with meals (may
be in reduced dose).
 Management of diabetes during Ramadan
Specific measures

Type1 DM
Some experienced physicians conclude that Ramadan fasting is safe for typel patients with proper self-
monitoring of blood glucose and close supervision. Two insulin regimens have been studied successfully.
Three-dose insulin regimen - two doses before meals (sunset and dawn) of short acting insulin and one dose
in the late evening of intermediate-acting insulin.
Two-dose insulin regimen - evening insulin of combined short-acting and intermediate-acting insulin
equivalent to the previous morning dosage, and a predawn insulin consisting only of short-acting insulin.
 Prevention of DM
Diabetes mellitus, a chronic debilitating disease, is associated with a range of severe complications.
Prevention of diabetes is feasible and is evident in many studies done in various countries.
Prevention means preventing or delaying diabetes as well as the complications both in terms of
beginning and progression.
The prevention is done by modifying the modifiable risk factors.

Types of DM Prevention
Primary prevention Secondary prevention Tertiary prevention
aims to delay and/or
means early detection of diabetes
prevent further
refers to avoiding the onset and prompt initiation of treatment
progression of the
of the disease (diabetes) to prevent complications of
diabetic
diabetes.
complications.
 Primary prevention of DM

 Type2 diabetes is the commonest form of diabetes.

 Although a heterogeneous disorder, progression from insulin insensitivity to pre-diabetes,
then to diabetes is now well understood.
 The risk factors for type2 diabetes are: a) aging, b) family history of type2 diabetes, c) over-
weight/obesity, d) physical inactivity e) pregnancy, f) intra-uterine and early childhood
malnutrition g) stress and h) smoking.
 Except age and family history all others are amenable to modification.
 Many of these risk factors are common for other non-communicable diseases (NCDs).
 Primary prevention of type2 DM
• Prevention of type2 DM is important because:
• It is the most prevalent type of diabetes.
• It is putting on tremendous burden:
• Rapidly and enormously rising number.
• Acute and chronic complications; 50% patients present with chronic complications.
• 15% patients have depression.
• 8.4% of global all-cause mortality.
• Economic impact- diabetics spend 10.8% of total health expenditure globally.
• Diabetes care is still suboptimal; less than one-third patients achieve target HbA1c.It has
recognizable pre-diabetic stage.
• It has identifiable risk factors.
• It is preventable by simple measures.
• It is part of NCDs having shared risk factors and benefit of prevention.
• There is now substantial evidence that type2 DM can be prevented and its complications can also be
prevented or delayed. Identification of individuals at risk of developing diabetes can be done
effectively. Diabetes prevention programmes focus on lifestyle modification, specifically modest
weight loss and increased physical activity.
 Approach to Prevention of DM

Primary prevention can be achieved through two basic approaches:

• Population • High-risk
approach group
approach
1 2
 Approach to Prevention of DM

Primary prevention: Population approach

• Incorporation of basic • Creation of facilities for

information in school text book performing physical activities,
curriculums. like sports, gyms etc.
• Use of mass media, e.g. • Promotion of healthy eating
newspapers, radio, television etc. habits, like campaign against
• Use of social organizations, e.g. 'fast food culture' etc.
religious institutes, voluntary
organizations etc.

Creation of Care of risk

mass awareness factors
 Approach to Prevention of DM
Primary prevention: High-risk group approach

Identification of people at risk

Measurement of risk

Risk factor of DM
Modifiable risk Non modifiable risk
2 2
BMI above normal (>25 kg/m ; for the Asians >23 kg/m ) Age > 40 years
Habitual physical inactivity Positive family history of DM
Waist-hip ratio above normal( >0.9 for male; > 0.8 for female) Previously identified as IFG/IGT
Hypertension History of GDM or delivery of baby >9 1bs
Dyslipidemia Infertility, pregnancy loss
PCOS, acanthosisnigricans etc. Some ethnicities- asians
 Prevention of DM
Intervention
 It is done by ensuring weight management, regular physical activity, medical nutrition
therapy and even by using drugs (like metformin) to modify the risk factors.
Risks of type2 DM in Asian countries
 Bangladesh and other Asian countries are at higher risk of type2 diabetes and its complications because:
 Risk of type2 DM starts at lower BMI
 More prone to abdominal obesity, low muscle mass and insulin resistance
 Higher visceral or subcutaneous fat despite lower waist circumference or BMI
 Urbanization-rapid nutritional transition, reduced physical activity, mental stress
 Increase in smoking
 Intra-uterine or early childhood malnutrition
 Increased prevalence of GDM, risking mother and baby
 Chronic arsenic exposure
 Genetic susceptibility
 Earlier age of onset of DM
More vulnerable to some complications, e.g. CAD, stroke, nephropathy, some malignancies and all cause
mortality. Therefore, countries of this region should adopt their national policy to prevent diabetes mellitus.
 Primary prevention of type1 DM

• For type1 diabetes genetic and immunological markers are available but these are costly.
• It is not feasible to use them for population-based identification, but specific high-risk
groups can be screened. The cost effectiveness, and social and moral issues of such
screening activities remain unclear.
• Some suggested strategies include encouraging breast-feeding, use of antioxidants and
beta cell rest by giving insulin to individuals with identified genetic and immunological
markers.
• As yet there is no evidence to suggest that type1 diabetes can be prevented, but none-the-
less efforts continue, as it is a goal worth pursuing.
 Secondary prevention of DM

• Early detection of diabetes and prevention of micro- and macro-angiopathies in a

diabetic person is termed secondary prevention. Studies documented that
approximately 50% of type2 diabetic patients already have complications at detection
of their diabetes. Early detection of diabetes to initiate its treatment thereby to halt or
delay these complications is the aim of secondary prevention.
• Diabetes awareness in the community and amongst physicians to enhance the routine
screening of population at risk is important. Screening should be considered in all
individuals >40 years of age, and if normal should be repeated every 3 years. Screening
should be done at a younger age and/or more frequently in those with BMI >25
kg/m2 plus one or more additional risk factors of diabetes (in the previous table).
Testing for pre-diabetes should be done yearly.
 Target of secondary prevention of diabetes
Target of glycemic and lipid levels
Secondary prevention of DM
Blood (plasma) glucose



Fasting/pre-meal <6.0 mmol/L
Post-meal <8.0 mmol/L
HbAlc  <7%
 LDL cholesterol <100mg/dl
Blood lipids  HDL cholesterol >40 mg/dl (male) &>50 mg/dl (female)
 Triglyceride <1 50 mg/dl
Target of blood pressure
 Systolic <140mmofHg
BP
 Diastolic <80mmofHg
Target of body weight & obesity
 BMI* <25 kg/m2
BMI& Waist circumference (WC)
 WC <90 cm (male) & <80 cm (female)
Teaching, training & empowerment to take part in
Target of diabetic education treatment
 Tertiary prevention of DM

• Tertiary prevention
• Interventions designed to minimize consequences of diabetes and help rehabilitation fall under
this category. Here attempts are directed to contain damage by aggressive therapy to arrest or
delay progression of complications. Each complication may be addressed with special objectives
and strategies reducing morbidity and mortality.
• Screening for complications
• Type1 DM
• At or after 5 years of diagnosis (or earlier); then every year (in absence of complications)
• Type2 DM
• At diagnosis; then every year (in absence of complications)
Effective strategies of tertiary prevention

• Imp roved foot ca re • Control of hypertension

• Reduction of risk • Control of dyslipidemia
factors • Cessation of smoking
• Control of • Control of
hyperglycemia, etc. hyperglycemia, etc.

Prevention of Prevention of
lower limb cardiovascular
amputation disease
Effective strategies of tertiary prevention

• Control of • Control of
hypertension hypertension
• (When necessary) • Laser
low protein diet photocoagulation
• Control of • Control of
hyperglycemia, etc. hyperglycemia, etc.
Prevention of Prevention
renal disease of blindness
 Prevention of DM
• Diabetic complications account for 60% of diabetes related health care costs (direct costs) and
almost 80-90% of indirect costs. Preventing complications is therefore not only beneficial to
individuals but also to the society as a whole. Economic analysis from the different studies has
shown that prevention programmes are cost effective. Other studies also have shown that
simple measures, like education and awareness also help.
•
• Comprehensive care of diabetes with patient education and awareness about complications can
bring about a remarkable reduction in blindness, end-stage renal diseases (ESRD), lower
extremity amputation and cardiovascular events.
•
Stay home and Stay Safe

DLP Check Notice

http://www.badas-dlp.org BADAS