Principles of care in the diabetic surgical patient

Abstract

The prevalence of diabetes in the USA continues to grow at an alarming rate. While the risk factors for diabetes complications are well defined, many patients are not achieving recognized treatment goals and are at risk of developing complications, including peripheral vascular disease and podiatric problems. There are two major types of diabetes-Type 1 and Type 2. Type 1 diabetes develops into a from of insulin production while Type 2 diabetes develops because of insulin resistance with an inadequate supply of insulin to meet the increased need. When patients with diabetes are admitted to the hospital, they will almost always require insulin therapy. Optimal insulin coverage includes basal (background) insulin in conjunction with insulin. The bolus insulin dose is composed of a prandial (meal) component and a correction dose as needed. For patients eating normally the total daily dose of prandial insulin is approximately equal to the total basal dose. Based on a patient's total daily insulin requirement, one can calculate a correction factor or the amount of blood glucose lowering expected from 1 unit of insulin. Patients with Type 1 diabetes, because of their lack of insulin production, can never have all of their insulin held because of the risk of developing DKA. Adjustments in both the basal and bolus doses are required preoperatively. Patients in the ICU are best managed with an intravenous insulin infusion with dosing based on a validated protocol. Early discharge planning can help avoid delays in discharge due to diabetes-related issues.