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Diabetes Mellitus






  • Potential difficult airway (↓TMJ mobility, obesity)

  • Aspiration risk with gastroparesis 

  • End organ disease:

    • Hypertension, coronary artery disease, left ventricular hypertrophy & cardiomyopathy

    • Peripheral vascular disease 

    • Chronic kidney disease 

    • Neuropathy 

      • Autonomic instability

      • Chronic pain

  • Perioperative complications & management of blood glucose & medications: 

    • Related to severity of disease & control of blood glucose (hypoglycemia)

    • DKA or HONK

    • Hypoglycemia

    • Related to end organ disease




  • Evaluate severity of end organ dysfunction

  • Perioperative management of elevated blood glucose: Canadian Diabetes Association guidelines suggests 5-10 mmol/L

    • If only on PO hypoglycemics at home: start IV insulin infusion at 1-2 units/hr

    • If on insulin at home, divide 24 hr dose by 24 & give 1/2 to 2/3 that per hour as an IV insulin infusion

    • Consider bolusing a few units up front

  • Preoperatively (see SAMBA guidelines below): 

    • Type II diabetes, diet controlled: fast, check blood glucose

    • Type II diabetes, on oral hypoglycemics: fast, hold pills morning of surgery, check blood glucose 

    • Type II diabetes, on insulin: fast, insulin dose depends on type (see below), start D5W infusion 




  • Hyperglycemia (DKA, HONK)

  • Hypoglycemia



Special populations


  • Pregnancy:

    •  risk of DKA, HONK, pregnancy-induced hypertension, difficult airway, aspiration, pre-term labor, cesarean section, polyhydramnios, postoperative infection

    • For fetus: 

      • Macrosomia (birth trauma, shoulder dystocia, cesarean section, postpartum hemorrhage)

      • Glucose regulation (hypoglycemia)

      • Congenital malformations (cardiovascular, CNS, GI)

      • Respiratory distress syndrome 



Insulin Management Guidelines (SAMBA Guidelines)




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