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The Management of Diabetes in the Surgical Patient
The Management of Diabetes in the Surgical Patient CLlFFORD F. GASTINEAU, M.D.
THE CARE of the diabetic patient undergoing a surgical procedure is in some respects an exercise in pathologic physiology. The therapy must be based on a knowledge of the derangements of metabolism that may occur. Diabetes impairs some of the mechanisms that normally would act to preserve homeostasis during and following the stress of operation. In the physician's attempts to duplicate the normal mechanism for maintaining the concentration of glucose in body fluids within physiologic limits, complete success is rare. Unduly cautious administration of insulin may result in hyperglycemia and ketosis, but excessive doses of insulin may cause hypoglycemia; and if this latter is severe and prolonged, various undesirable consequences may result-including permanent injury to the central nervous system. 4 The diabetic subject is more vulnerable to depletion of protein, ketosis, and hyperlipemia than is the nondiabetic. Disturbances in water and salt balances may occur with less provocation. Diabetic autonomic neuropathy, if present, can impair the mechanisms for stabilizing blood pressure. 7 PREOPERATIVE EVALUATION
A simple but important aid to the anticipation of some of these disturbances is the diabetic history. Detailed questioning of the patient about his diabetes may seem tedious, but knowledge of previous reactions to stress and susceptibility to hypoglycemia or ketoacidosis may enable one to avoid serious difficulties. Although there are many transitional forms, diabetes is often divided into two contrasting categories: the juvenile or insulin-sensitive, and the adult or insulin-insensitive. The juvenile form is characterized by susceptibility to ketoacidosis, relatively large changes in carbohydrate metabolism with minor variation of insulin dose, failure to respond to the sulfonylureas, and commonly onset in the first three decades of life. The adult variety is marked by relative resistance to ketogenic forces, stability of blood sugar levels with variations in insulin dosage, common but not invariable response to the 1023
1024
CLIFFORD
F.
GAS'l'INEAU
sulfonylureas, and onset beyond the fourth decade. If questioning enables one to classify the patient's diabetes in one of these two eategories, the potential hazards may be anticipated. Examination of the patient for evidence of impaired arterial circulation in the extremities and peripheral neuropathy may yield information which warns of need for more careful protection of extremities from pressure, heat, or cold. Precautions to avoid pressure over the ulnar, radial, and peroneal nerves during the anesthetic period are particularly important, since nerve palsies seem to be caused by less pressure in diabetic patients than in others." The effect of different surgical procedures on the behavior of the diabetes is difficult to predict. In general, the greater the extent and severity of the operation, the greater will be the disturbance of carbohydrate metabolism; but there arc many exceptions. Thyroidectomy for hyperthyroidism, surgical fixation of fractures, and anal operations often seem to aggravate the state of diabetes more than other procedures. Anesthesia with ether or chloroform aggravates hyperglycemia and ketosis, but most modern anesthetic agents have relatively little effect on the diabetes. Anoxia may cause hyperglycemia through stimUlating glycogenolysis. 1 Precautions for the care of diabetie patients during and following surgical procedures cannot be reduced completely to routine because of the variations in the nature of the diabetes, and differences among operations. Knowledge of the physiologic principles, however, should enable one to formulate plans appropriate to the problem at hand. EMERGENCY SURGERY
If an operation must be done in an emergency, as for appendicitis, dental abscess, or fracture, often a compromise must be made between the needs for controlling the diabetes and the necessity for prompt surgical intervention. Often the stress of the condition requiring surgical intervention aggravates the diabetes and makes control before operation difficult. The administration of appropriate doses of insulin and of solutions of glucose and electrolytes may correct~at least partly~ moderate ketosis and electrolyte deficits within a few hours while other preparations for operation are being made. Given this preoperative start, the process of bringing the diabetes under control can be completed more readily once the stressful process is corrected surgically. In the situation outlined, however, the decision on optimal timing of the operation may be difficult. ELECTIVE SURGERY
Elective surgery permits more thorough preparation and some generalizations. The operation should be scheduled as early in the day as
The
~[anagement
of Diabetes in the Surgical Patient
102.5
feasible so that th(~ period of fasting and hence ketogenesis will be minimized. There is a possibility that hypoglycemia will be present on the morning of operation as an effect of insulin or of a sulfonylurea administered on the preceding day. For this reason the dose of longacting insulin on the day before operation should be made somewhat smaller than usual, especially if fasting levels of blood sugar have been normal or only slightly elevated. Short-acting insulin in multiple doses can be substituted for long-acting insulin on that day to avoid the hazard of hypoglycemia on the morning of operation, but usually this is necessary only in cases of very unstable diabetes. Hypoglycemia from the sulfonylureas (tolbutamide and chlorpropamide) is an uncommon hazard, but if it does occur it most likely will be in an older or poorly nourished patient. Nevertheless, it is well to stop giving these drugs several days before operation or to be certain that glucose solutions are given until the patient is able to begin eating again. Of the oral hypoglycemic agents, chlorpropamide (Diabinese) has the most prolonged action and there is perhaps some hazard of hypoglycemia in the fasting individual even two to four days after the last dose of it. The hypoglycemic effect of tolbutamide (Orinase) is shorter. Phenformin (DBI)." the third of the currently available oral hypoglycemic agents, is not a sulfonylurea and in the human subject does not lower concentrations of blood sugar below normal limits except when given in conjunction with insulin. The incompatibility of the sulfonylureas and alcohol should be mentioned also, since alcohol is sometimes given parenterally during the postoperative period. Administration of alcohol to a patient taking onc of the sulfonylureas may result in flushing, abdominal distress, nausea, and vomiting. 8 In this respect the sulfonylureas are analogous to disulfiram (Antabuse), the dru!l; used in the conditioned-reflex treatment of alcoholism. INSULIN THE DAY OF OPERATION
If the patient ordinarily does not require insulin, there is no need to give it on the morning of operation. In contrast, the insulin-dependent diabetic must have some insulin acting at all times to prevent ketogenesis. If insulin is withheld during the several hours required for operation and recovery from anesthesia, an appreciable degree of ketosis may develop. Hence it is desirable ordinarily to give some insulin prior to operation, keeping in mind the hazards of hypoglycemia from excessive insulin on one hand and of ketosis from an inadequate amount on the other. The dose of insulin given before operation should be scaled downward in the individual known to be susceptible to insulin reactions. It is needless to point out the difficulty of recognizing hypoglycemia in the
1026
CLIFFORD
F.
GAS'l'INEAU
anesthetized patient and the potentially serious danger of that situation. Generally it is safe to give one-fourth to one-third of the usual daily dose in the form of Ultralente or Protamine insulin. Although these have a slow onset of action, even such cautious doses as mentioned ean cause hypoglycemia after several hours if no glucose is given. For this reason it is well to infuse a glucose solution slowly during operation and the post-anesthesia recovery period. Blood samples for measurement of glueose eontent ean be drawn before the infusion is started, and the results will be available during the post-anesthesia recovery period for guidance in estimating the needs for further insulin. Another sample can be obtained postoperatively if there is concern about the possibility of hypoglyeemia or hyperglycemia of undue degree. Information of some usefulness can be obtained even though glucose is being infused at the moment. The use of fructose solutions during these somewhat precarious hours introduces an additional uncertainty in that fructose is measured by the usual tests for blood glucose but is not utilized by the brain and hence does not correct directly the effects of a low blood glucose level. There is little advantage in the use of fructose during and immediately following operation; and in the interest of simplicity, carbohydrate is given ordinarily in the form of glucose. It is desirable that 150 to 200 gm. of glucose be given during each 24-hour period that parenteral feeding is required. Crystalline insulin frequently is added to solutions of glucose being given intravenously in a ratio of 10 units to 50 gm. of glucose. There is some doubt how much of the insulin given in this manner actually reaches the body, however, since insulin in dilute solutions tends to adhere to glass surfaces. 6 One may prefer to depend on crystalline or Semilente insulin given subcutaneously at intervals of four to six hours after operation, the dose being determined by the urine tests at the time. Generally, the amount of insulin needed during the 24 hours after operation will approximate the usual daily dose of insulin. One particularly important exception is the woman undergoing obstetrical delivery, either cesarean or from below. The need for insulin during the first several postpartum days may be one-fourth or less of the requirement before delivery. Severe hypoglycemic episodes may occur if this reduction in need for insulin is not anticipated. In contrast, the need for insulin may be multiplied several times in the patient undergoing reduction of a fracture or thyroidectomy for Graves' disease. THE POSTOPERATIVE PERIOD
A variety of plans can be used successfully for administering insulin during the days following operation. Administration of crystalline insulin at intervals of four to six hours, the dose depending on urine tests, permits fine adjustments with small hazard of severe or prolonged
The Management of Diabetes in the Surgical Patient
1027
hypoglycemia. However, this scheme may permit rapid development of ketoacidosis if one or two doses of insulin are omitted for any reason. At the other extreme one can give one's estimate of the day's need for insulin as a single dose of intermediate insulin each morning. Supplemental doses of crystalline insulin or additional glucose during the day may be needed, since even the most skillful clinician cannot predict aceurately the need for insulin in the next 24 hours in the unstable diabetic. This program may be very successful and convenient for the patient with a more stable variety of diabetes, however. As a compromise a moderate dose of Ultralente or Protamine insulin may be given each morning and several supplements of crystalline or Semilente insulin during the day, the size of the supplement being governed by the results of the urine tests. This plan has the advantage of permitting reassessment of the need for insulin several times during each 24 hours, but the long-aeting insulin ensures that the support of some insulin activity is never completely removed. W oodyatt proposed and used a scheme of equal feedings at six-hour intervals prior to operation with regular insulin administered at each feeding. The surgical procedure was carried out during the second half of a six-hour period when the insulin requirement for this program was known. During the postoperative period the glucose equivalent of a meal was given in the form of 10 per cent glucose administered subcutaneously over each six-hour period, and insulin dosage was varied according to results of the urine and blood tests. Although this plan has many advantages, it is seldom used because of the inconvenience of serving meals and administering insulin at these unconventional hours. The feeding of the diabetic patient during the postoperative period may be difficult. Foods containing sugars and ordinarily forbidden to diabetics may have to be used if other foods are not tolerated. Usually, however, the dietitian can plan diets that adhere to usual diabetic principles and are graduated in caloric content and variety appropriate to the stage of recovery from the surgical treatment. It is well to remember that although food may be swallowed it is not necessarily absorbed. Food residing in the stomach will not prevent hypoglycemia from insulin administered on the assumption that normal alimentation is taking place. Impaired gastric emptying is not uncommon in any postoperative patient and is particularly likely to occur in the diabetic with visceral autonomic neuropathy.2 The taking of adequate amounts of protein is particularly important for the unstable diabetic during recovery from operation. Inevitably, in the labile diabetic, glyconeogenesis and hence destruction of protein in some degree will occur during portions of each 24 hours. This tendency can be minimized by the administration of adequate amounts of carbohydrate and necessary insulin. The importance of trying to abolish the negative nitrogen balance following operation by generous parenteral
1028
CLU'FORD
F.
GAS'l'INEAU
and early oral protein feedings has been debated hotly in surgical cireles for a number of years. Whatever one believes in this respect, one should remember that the patient with incompletely controlled diabetes will suffer a greater destruction of protein than will the nondiabetic postoperative patient and therefore will need greater efforts to restore protein. If glycosuria and the insulin requirement increase unexpectedly during the postoperative period, one should look for some complication such as a wound infection or a myocardial or pulmonary infarction. This can be expressed as an aphorism: if diabetes flares, look for infection or infarction. The patient whose diabetes is controlled reasonably well by ordinary standards does not seem to be unduly susceptible to infection. On the other hand, if control is poor, infection may spread rapidly. The mechanism of this decrease in resistance to infection is not clear; possibly it results from the hyperglycemia itself and the depletion of body protein with consequent involvement of some immune mechanisms. Infections of the urinary tract may be a special category, and the possibility of bacteremic shock from gram-negative bacilli should be kept in mind in diabetic subjects undergoing urologic procedures. 3 The patient undergoing amputation for a gangrenous lower extremity may present difficult problems. Such patients frequently have coronaryartery disease and are vulnerable to myocardial infarction or congestive failure. The relatively ischemic amputation stump may become infected or fail to heal. Frequently the healing of such a stump is in doubt, and the degree of control of the diabetes may decide the outcome. Therefore meticulous control of blood sugar is desirable in this situation. Removal of a gangrenous leg may so moderate the diabetes that good control becomes easy in the post-amputation period. SUMMARY
The diabetic patient undergoing operation needs particular attention to maintenance of adequate protein nutrition and to protection from injury to extremities by heat or pressure. The program for controlling the diabetes should be adapted to the charaeter of that patient's diabetes and the surgical procedure planned. REFERENCES 1. Adriani, John: The Pharmacology of Anesthetic Drugs: A Syllabus for Students
and Clinicians. Ed. 4, Springfield, Illinois, CharleR C Thomas, Publisher, 1960, 232 pp. 2. Goodman, J. I., Baumoel, Siegfried, Frankcl, Leonard, Marcus, L. J., and Wassermann, Sigmund: The Diabetie Neuropathies. Springfield, Illinois, Charles C Thomas, Publisher, 1953, p. 24. 3. Martin, W. J., and McHenry, M. C.: Diabetes Mellitus Complicated by Bac-
The Management of D1:abetes in the Surgical Patient 4. 5.
6. 7. 8. 9.
1029
teremia Caused by Gram-Negative Bacilli: Further Observations. Proc. Staff Meet., Mayo Clin. 36: 507-51G (Sept.. 27) 1961. Meyer, J. S., and Portnoy, H. D.: Localized Cerebral Hypoglyeemia Simulating Stroke: A Clinical and Experimental Htudy. Neurology 8: 601-614 (Aug.) 1958. Mulder, D. W., Lambert, E. H., Bastron, J. A., and Sprague, R. G.: The Neuropathies Associated with Diabetes Mellitus: A Clinical and Electromyographic Study of 103 Unselected Diabetic Patients. Neurology 11: 275-284 (Apr.) 1961. Newerly, Katherina, and Berson, S. A.: Lack of Specificity of Insulin-Im-Binding by Isolated Rat Diaphragm. Proc. Soc. Exper. BioI. & Med. 94: 751-755 (Apr.) 1957. Ode!, H. M., Roth, Grace M., and Keating, F. R., Jr.: Autonomie Neuropathy Simulating the Effeets of Sympathectomy as a Complication of Diabetes Mellitus. Diabetes 4: \)2-98 (Mar.-Apr.) 1955. Signorelli, Saverio: Tolerance for Alcohol in Patients on Chlorpropamide. Ann. New York Acad. Sc. 74: 900-90:3 (Mar. 30) 1959. Woodyatt, R. '1'.: Diabetes Mellitus. In Cecil, R. L.: A Text-book of Medicine. Ed. 3, Philadelphia, W. B. Saunders Company, 1933, pp. 628-659.
THE CARE of the diabetic patient undergoing a surgical procedure is in some respects an exercise in pathologic physiology. The therapy must be based on a knowledge of the derangements of metabolism that may occur. Diabetes impairs some of the mechanisms that normally would act to preserve homeostasis during and following the stress of operation. In the physician's attempts to duplicate the normal mechanism for maintaining the concentration of glucose in body fluids within physiologic limits, complete success is rare. Unduly cautious administration of insulin may result in hyperglycemia and ketosis, but excessive doses of insulin may cause hypoglycemia; and if this latter is severe and prolonged, various undesirable consequences may result-including permanent injury to the central nervous system. 4 The diabetic subject is more vulnerable to depletion of protein, ketosis, and hyperlipemia than is the nondiabetic. Disturbances in water and salt balances may occur with less provocation. Diabetic autonomic neuropathy, if present, can impair the mechanisms for stabilizing blood pressure. 7 PREOPERATIVE EVALUATION
A simple but important aid to the anticipation of some of these disturbances is the diabetic history. Detailed questioning of the patient about his diabetes may seem tedious, but knowledge of previous reactions to stress and susceptibility to hypoglycemia or ketoacidosis may enable one to avoid serious difficulties. Although there are many transitional forms, diabetes is often divided into two contrasting categories: the juvenile or insulin-sensitive, and the adult or insulin-insensitive. The juvenile form is characterized by susceptibility to ketoacidosis, relatively large changes in carbohydrate metabolism with minor variation of insulin dose, failure to respond to the sulfonylureas, and commonly onset in the first three decades of life. The adult variety is marked by relative resistance to ketogenic forces, stability of blood sugar levels with variations in insulin dosage, common but not invariable response to the 1023
1024
CLIFFORD
F.
GAS'l'INEAU
sulfonylureas, and onset beyond the fourth decade. If questioning enables one to classify the patient's diabetes in one of these two eategories, the potential hazards may be anticipated. Examination of the patient for evidence of impaired arterial circulation in the extremities and peripheral neuropathy may yield information which warns of need for more careful protection of extremities from pressure, heat, or cold. Precautions to avoid pressure over the ulnar, radial, and peroneal nerves during the anesthetic period are particularly important, since nerve palsies seem to be caused by less pressure in diabetic patients than in others." The effect of different surgical procedures on the behavior of the diabetes is difficult to predict. In general, the greater the extent and severity of the operation, the greater will be the disturbance of carbohydrate metabolism; but there arc many exceptions. Thyroidectomy for hyperthyroidism, surgical fixation of fractures, and anal operations often seem to aggravate the state of diabetes more than other procedures. Anesthesia with ether or chloroform aggravates hyperglycemia and ketosis, but most modern anesthetic agents have relatively little effect on the diabetes. Anoxia may cause hyperglycemia through stimUlating glycogenolysis. 1 Precautions for the care of diabetie patients during and following surgical procedures cannot be reduced completely to routine because of the variations in the nature of the diabetes, and differences among operations. Knowledge of the physiologic principles, however, should enable one to formulate plans appropriate to the problem at hand. EMERGENCY SURGERY
If an operation must be done in an emergency, as for appendicitis, dental abscess, or fracture, often a compromise must be made between the needs for controlling the diabetes and the necessity for prompt surgical intervention. Often the stress of the condition requiring surgical intervention aggravates the diabetes and makes control before operation difficult. The administration of appropriate doses of insulin and of solutions of glucose and electrolytes may correct~at least partly~ moderate ketosis and electrolyte deficits within a few hours while other preparations for operation are being made. Given this preoperative start, the process of bringing the diabetes under control can be completed more readily once the stressful process is corrected surgically. In the situation outlined, however, the decision on optimal timing of the operation may be difficult. ELECTIVE SURGERY
Elective surgery permits more thorough preparation and some generalizations. The operation should be scheduled as early in the day as
The
~[anagement
of Diabetes in the Surgical Patient
102.5
feasible so that th(~ period of fasting and hence ketogenesis will be minimized. There is a possibility that hypoglycemia will be present on the morning of operation as an effect of insulin or of a sulfonylurea administered on the preceding day. For this reason the dose of longacting insulin on the day before operation should be made somewhat smaller than usual, especially if fasting levels of blood sugar have been normal or only slightly elevated. Short-acting insulin in multiple doses can be substituted for long-acting insulin on that day to avoid the hazard of hypoglycemia on the morning of operation, but usually this is necessary only in cases of very unstable diabetes. Hypoglycemia from the sulfonylureas (tolbutamide and chlorpropamide) is an uncommon hazard, but if it does occur it most likely will be in an older or poorly nourished patient. Nevertheless, it is well to stop giving these drugs several days before operation or to be certain that glucose solutions are given until the patient is able to begin eating again. Of the oral hypoglycemic agents, chlorpropamide (Diabinese) has the most prolonged action and there is perhaps some hazard of hypoglycemia in the fasting individual even two to four days after the last dose of it. The hypoglycemic effect of tolbutamide (Orinase) is shorter. Phenformin (DBI)." the third of the currently available oral hypoglycemic agents, is not a sulfonylurea and in the human subject does not lower concentrations of blood sugar below normal limits except when given in conjunction with insulin. The incompatibility of the sulfonylureas and alcohol should be mentioned also, since alcohol is sometimes given parenterally during the postoperative period. Administration of alcohol to a patient taking onc of the sulfonylureas may result in flushing, abdominal distress, nausea, and vomiting. 8 In this respect the sulfonylureas are analogous to disulfiram (Antabuse), the dru!l; used in the conditioned-reflex treatment of alcoholism. INSULIN THE DAY OF OPERATION
If the patient ordinarily does not require insulin, there is no need to give it on the morning of operation. In contrast, the insulin-dependent diabetic must have some insulin acting at all times to prevent ketogenesis. If insulin is withheld during the several hours required for operation and recovery from anesthesia, an appreciable degree of ketosis may develop. Hence it is desirable ordinarily to give some insulin prior to operation, keeping in mind the hazards of hypoglycemia from excessive insulin on one hand and of ketosis from an inadequate amount on the other. The dose of insulin given before operation should be scaled downward in the individual known to be susceptible to insulin reactions. It is needless to point out the difficulty of recognizing hypoglycemia in the
1026
CLIFFORD
F.
GAS'l'INEAU
anesthetized patient and the potentially serious danger of that situation. Generally it is safe to give one-fourth to one-third of the usual daily dose in the form of Ultralente or Protamine insulin. Although these have a slow onset of action, even such cautious doses as mentioned ean cause hypoglycemia after several hours if no glucose is given. For this reason it is well to infuse a glucose solution slowly during operation and the post-anesthesia recovery period. Blood samples for measurement of glueose eontent ean be drawn before the infusion is started, and the results will be available during the post-anesthesia recovery period for guidance in estimating the needs for further insulin. Another sample can be obtained postoperatively if there is concern about the possibility of hypoglyeemia or hyperglycemia of undue degree. Information of some usefulness can be obtained even though glucose is being infused at the moment. The use of fructose solutions during these somewhat precarious hours introduces an additional uncertainty in that fructose is measured by the usual tests for blood glucose but is not utilized by the brain and hence does not correct directly the effects of a low blood glucose level. There is little advantage in the use of fructose during and immediately following operation; and in the interest of simplicity, carbohydrate is given ordinarily in the form of glucose. It is desirable that 150 to 200 gm. of glucose be given during each 24-hour period that parenteral feeding is required. Crystalline insulin frequently is added to solutions of glucose being given intravenously in a ratio of 10 units to 50 gm. of glucose. There is some doubt how much of the insulin given in this manner actually reaches the body, however, since insulin in dilute solutions tends to adhere to glass surfaces. 6 One may prefer to depend on crystalline or Semilente insulin given subcutaneously at intervals of four to six hours after operation, the dose being determined by the urine tests at the time. Generally, the amount of insulin needed during the 24 hours after operation will approximate the usual daily dose of insulin. One particularly important exception is the woman undergoing obstetrical delivery, either cesarean or from below. The need for insulin during the first several postpartum days may be one-fourth or less of the requirement before delivery. Severe hypoglycemic episodes may occur if this reduction in need for insulin is not anticipated. In contrast, the need for insulin may be multiplied several times in the patient undergoing reduction of a fracture or thyroidectomy for Graves' disease. THE POSTOPERATIVE PERIOD
A variety of plans can be used successfully for administering insulin during the days following operation. Administration of crystalline insulin at intervals of four to six hours, the dose depending on urine tests, permits fine adjustments with small hazard of severe or prolonged
The Management of Diabetes in the Surgical Patient
1027
hypoglycemia. However, this scheme may permit rapid development of ketoacidosis if one or two doses of insulin are omitted for any reason. At the other extreme one can give one's estimate of the day's need for insulin as a single dose of intermediate insulin each morning. Supplemental doses of crystalline insulin or additional glucose during the day may be needed, since even the most skillful clinician cannot predict aceurately the need for insulin in the next 24 hours in the unstable diabetic. This program may be very successful and convenient for the patient with a more stable variety of diabetes, however. As a compromise a moderate dose of Ultralente or Protamine insulin may be given each morning and several supplements of crystalline or Semilente insulin during the day, the size of the supplement being governed by the results of the urine tests. This plan has the advantage of permitting reassessment of the need for insulin several times during each 24 hours, but the long-aeting insulin ensures that the support of some insulin activity is never completely removed. W oodyatt proposed and used a scheme of equal feedings at six-hour intervals prior to operation with regular insulin administered at each feeding. The surgical procedure was carried out during the second half of a six-hour period when the insulin requirement for this program was known. During the postoperative period the glucose equivalent of a meal was given in the form of 10 per cent glucose administered subcutaneously over each six-hour period, and insulin dosage was varied according to results of the urine and blood tests. Although this plan has many advantages, it is seldom used because of the inconvenience of serving meals and administering insulin at these unconventional hours. The feeding of the diabetic patient during the postoperative period may be difficult. Foods containing sugars and ordinarily forbidden to diabetics may have to be used if other foods are not tolerated. Usually, however, the dietitian can plan diets that adhere to usual diabetic principles and are graduated in caloric content and variety appropriate to the stage of recovery from the surgical treatment. It is well to remember that although food may be swallowed it is not necessarily absorbed. Food residing in the stomach will not prevent hypoglycemia from insulin administered on the assumption that normal alimentation is taking place. Impaired gastric emptying is not uncommon in any postoperative patient and is particularly likely to occur in the diabetic with visceral autonomic neuropathy.2 The taking of adequate amounts of protein is particularly important for the unstable diabetic during recovery from operation. Inevitably, in the labile diabetic, glyconeogenesis and hence destruction of protein in some degree will occur during portions of each 24 hours. This tendency can be minimized by the administration of adequate amounts of carbohydrate and necessary insulin. The importance of trying to abolish the negative nitrogen balance following operation by generous parenteral
1028
CLU'FORD
F.
GAS'l'INEAU
and early oral protein feedings has been debated hotly in surgical cireles for a number of years. Whatever one believes in this respect, one should remember that the patient with incompletely controlled diabetes will suffer a greater destruction of protein than will the nondiabetic postoperative patient and therefore will need greater efforts to restore protein. If glycosuria and the insulin requirement increase unexpectedly during the postoperative period, one should look for some complication such as a wound infection or a myocardial or pulmonary infarction. This can be expressed as an aphorism: if diabetes flares, look for infection or infarction. The patient whose diabetes is controlled reasonably well by ordinary standards does not seem to be unduly susceptible to infection. On the other hand, if control is poor, infection may spread rapidly. The mechanism of this decrease in resistance to infection is not clear; possibly it results from the hyperglycemia itself and the depletion of body protein with consequent involvement of some immune mechanisms. Infections of the urinary tract may be a special category, and the possibility of bacteremic shock from gram-negative bacilli should be kept in mind in diabetic subjects undergoing urologic procedures. 3 The patient undergoing amputation for a gangrenous lower extremity may present difficult problems. Such patients frequently have coronaryartery disease and are vulnerable to myocardial infarction or congestive failure. The relatively ischemic amputation stump may become infected or fail to heal. Frequently the healing of such a stump is in doubt, and the degree of control of the diabetes may decide the outcome. Therefore meticulous control of blood sugar is desirable in this situation. Removal of a gangrenous leg may so moderate the diabetes that good control becomes easy in the post-amputation period. SUMMARY
The diabetic patient undergoing operation needs particular attention to maintenance of adequate protein nutrition and to protection from injury to extremities by heat or pressure. The program for controlling the diabetes should be adapted to the charaeter of that patient's diabetes and the surgical procedure planned. REFERENCES 1. Adriani, John: The Pharmacology of Anesthetic Drugs: A Syllabus for Students
and Clinicians. Ed. 4, Springfield, Illinois, CharleR C Thomas, Publisher, 1960, 232 pp. 2. Goodman, J. I., Baumoel, Siegfried, Frankcl, Leonard, Marcus, L. J., and Wassermann, Sigmund: The Diabetie Neuropathies. Springfield, Illinois, Charles C Thomas, Publisher, 1953, p. 24. 3. Martin, W. J., and McHenry, M. C.: Diabetes Mellitus Complicated by Bac-
The Management of D1:abetes in the Surgical Patient 4. 5.
6. 7. 8. 9.
1029
teremia Caused by Gram-Negative Bacilli: Further Observations. Proc. Staff Meet., Mayo Clin. 36: 507-51G (Sept.. 27) 1961. Meyer, J. S., and Portnoy, H. D.: Localized Cerebral Hypoglyeemia Simulating Stroke: A Clinical and Experimental Htudy. Neurology 8: 601-614 (Aug.) 1958. Mulder, D. W., Lambert, E. H., Bastron, J. A., and Sprague, R. G.: The Neuropathies Associated with Diabetes Mellitus: A Clinical and Electromyographic Study of 103 Unselected Diabetic Patients. Neurology 11: 275-284 (Apr.) 1961. Newerly, Katherina, and Berson, S. A.: Lack of Specificity of Insulin-Im-Binding by Isolated Rat Diaphragm. Proc. Soc. Exper. BioI. & Med. 94: 751-755 (Apr.) 1957. Ode!, H. M., Roth, Grace M., and Keating, F. R., Jr.: Autonomie Neuropathy Simulating the Effeets of Sympathectomy as a Complication of Diabetes Mellitus. Diabetes 4: \)2-98 (Mar.-Apr.) 1955. Signorelli, Saverio: Tolerance for Alcohol in Patients on Chlorpropamide. Ann. New York Acad. Sc. 74: 900-90:3 (Mar. 30) 1959. Woodyatt, R. '1'.: Diabetes Mellitus. In Cecil, R. L.: A Text-book of Medicine. Ed. 3, Philadelphia, W. B. Saunders Company, 1933, pp. 628-659.