QuestionSBA
QuestionChoice
Diabetic patients who are fasting should be placed at the beginning of the surgical list to minimise the duration of the fast and the complications of suboptimal glucose control, which include dizziness, sweating, palpitations and, if severe, loss of consciousness.
10017231
a
A 43 year old insulin-dependant diabetic lady undergoing a hernia repair
QuestionChoice
Although this case may prove difficult from an anaesthetics point of view due to the difficulties with controlling blood pressure and risk of catecholamine surge during surgery, limiting fasting duration in a patient with diabetes takes priority.
10017233
c
A 21 year old man undergoing an elective surgery to remove a pheochromocytoma
QuestionChoice
Infectious patients should be placed at the end of the surgical list to reduce the risk of infecting other patients.
10017234
d
A 45 year old patient with miliary tuberculosis undergoing an elective lobectomy
QuestionChoice
There is no particular reason why this patient should be placed at the start of the list.
10017232
b
An 88 year old man undergoing an elective hip replacement surgery
QuestionChoice
There is no particular reason why this patient should be placed at the start of the list.
10017235
e
A 44 year old lady undergoing an elective laparoscopic cholecystectomy
Concept
Chapter
# COPD

Patients with COPD are at higher risk of post-op complications than other patients because of their impaired respiratory function. It is therefore advisable to arrange the following tests before surgery:

- Lung function tests
- Chest x-ray
- Arterial blood gas (if the patient is known to retain carbon dioxide)

Furthermore, it is prudent to encourage patients to give up smoking before the operation and to start chest physio early after the operation.

# Drugs to stop

- **Cardiovascular drugs:** Clopidogrel should be stopped 7 days before surgery, warfarin should be (generally) stopped 5 days before surgery and instead patients should be on low molecular weight heparin until the night before, ACE inhibitors should be stopped the day before surgery.
- **Combined oral contraceptive pill** should be stopped 4-6 weeks before surgery, and re-started at least 2 weeks after surgery (when the patient is mobile). This reduces the risk of DVT.

# Patients taking steroids
When the body experiences acute stress (e.g. illness, trauma, surgery), the steroid demand increases. 

Patients on long term steroids cannot respond to this demand because their adrenal function is suppressed.

Therefore, patients who are on long term steroids usually need more steroids than usual during periods of physiological stress e.g. surgery or acute illness.


## Management

Peri-operative management is as follows:

1. Switch oral steroids to 50-100mg IV hydrocortisone.
2. If there is associated hypotension then fludrocortisone can be added.
3. For minor operations oral prednisolone can be restarted immediately post-operatively. If the surgery is major then they may require IV hydrocortisone for up to 72 hours post-op.

# Diabetes
Peri-operative management of diabetes, both non-insulin-dependent (type 2 diabetes) and insulin-dependent (type 1 diabetes), involves careful monitoring and adjustment of medication regimens to mitigate the risk of peri-operative complications. The need for specific peri-operative management in diabetics arises due to physiological changes in response to stress (such as surgery), combined with the patient's underlying metabolic disorder. Surgical stress can induce hyperglycemia, and alterations in medication timing or dosage may be necessary due to fasting or changes in renal function.

## Potential complications

-   **Hyperglycemia**: Characterised by blood glucose levels >180 mg/dL, symptoms include polyuria, polydipsia, and unexplained weight loss.
-   **Hypoglycemia**: Characterised by blood glucose levels <70 mg/dL, symptoms include palpitations, tremor, sweating, anxiety, and confusion.
-   **Diabetic Ketoacidosis (DKA)**: Common in type 1 diabetics, symptoms include polyuria, polydipsia, nausea, vomiting, abdominal pain, and fruity-smelling breath.
-   **Lactic Acidosis**: A potential complication of metformin use, especially in renal impairment. Symptoms include abdominal discomfort, nausea, vomiting, muscle pain, and rapid breathing.


## Management


| Drug | Plan |
| ---------------------------- | ---------------------------------------------- |
| Metformin (taken once daily) | Take during the morning of surgery |
| DDP-IV inhibitors | Take during the morning of surgery |
| GLP-1 analogues | Take during the morning of surgery |
| SGLT-2 inhibitors | Omit the day of surgery due to the risk of DKA |

For insulin-dependent diabetics, key principles are:

1.  Schedule the patient as early on the theatre list as possible, minimising the amount of time the patient is nil by mouth.
2.  If on long-acting insulin, this should be continued but reduced by 20%.
3.  Stop any other insulin and begin sliding scale insulin infusion from when the patient is placed nil by mouth.
4.  Continue infusion until the patient is able to eat post-operatively.
5.  Switch to the normal insulin regimen around their first meal.

*For some operations (particularly those that do not require contrast media) metformin does not need to be stopped, but one should always consider the risk of lactic acidosis.

After surgery, all oral medications should generally be restarted the morning following surgery.



# NICE Guidelines

[NICE Guidelines on Diabetes management during the Peri-operative period](https://bnf.nice.org.uk/treatment-summaries/diabetes-surgery-and-medical-illness/)
3268
5406
Peri-operative Medication Optimisation
Topic
7
General Surgery
15990
Diabetic patients should be prioritised for surgery to reduce fasting duration and prevent complications from poor glucose control.
You are a foundation year one doctor on a general surgery rotation and are reviewing the cases for the list for the next few days.

Which of the following cases should be placed at the start of the surgical list for the day?
a