Diabetes in all its forms (diet controlled, medication controlled and insulin controlled) impacts all surgery patients. Since diabetics are more prone to coronary artery disease and blood chemistry alterations they require more extensive lab work including electrocardiograms before surgery and should be medically cleared for surgery by their internist. After surgery their healing time is prolonged, fluid balance is altered and they are more prone to infection. Therefore care after surgery including insulin doses should be performed under the guidance of the physician who medically cleared the patient for surgery accounting for the type of surgery performed and the patient’s condition.
For surgery of any kind in diabetics the goal is to complete the surgery without the patient experiencing keto-acidosis, high blood sugar or low blood sugar levels. This can be reached by one of 3 approaches
- no insulin-no sugar where the patient is fasted before and during surgery, takes no insulin the day of surgery and is given no intraveonus sugar
- a 1/3 to 2/3 split dose of insulin and intravenous sugar given during surgery
- the patient is given continuos insulin intravenously and blood sugar is monitored during surgery
For most cosmetic surgery patients who are not seriously and undergo more minor or shorter time operative procedures like rhinoplasty, blepharoplasty, breast augmentation, liposuction etc. the no insulin-no sugar approach is adequate. For longer procedures that are more involved such as belt lipectomy the split dose insulin and intravenous sugar approach are more appropriate. For seriously ill patients who may be undergoing reconstructive surgery and are not likely candidates for cosmetic surgery continuous intravenous infusion of insulin and sugar adjusted for blood sugar readings during surgery is most appropriate.
No special treatment is required for diabetics controlled by diet especially if the surgery is minor.
The care of patients whose diabetes is controlled by oral medications is more complicated. Most can be treated by the no insulin-no sugar approach taking their last dose of medication on the day before cosmetic surgery and then resuming it once they start eating after surgery. If the medication is a long acting sulfonylurea (like Glipizide) it should be stopped 3 days before surgery. If it is active in the body and the patient does not eat because of surgery the blood sugar level can become dangerously low. These patients are more likely to need blood sugar levels read right before, during and/or after surgery especially if the surgery time is longer than a few hours. They may also require a temporary switch to insulin from oral medications around the time of surgery.
I had a borderline diabetic patient whose diabetes was controlled by diet alone. The day following surgery their pancreas produced so little insulin that the blood sugar and potassium levels became alarmingly high. This was the body’s response to the stress of surgery. Luckily the surgery was performed in the hospital and the patient stayed in the hospital afterward. Administering bicarbonate intravenously and insulin normalized the blood chemistry curing a potentially disastrous problem. Unabated the abnormal blood chemistry can lead to coma, seizures and even death. Lengthy cosmetic procedures should be performed in a hospital in these patients and the blood sugar levels checked periodically after surgery.
Because of all of the above if you are a diabetic and your plastic surgeon is operating on more than one patient on the day of your surgery – you must be the first case of the day. Also lengthy cosmetic procedures should be performed in a hospital setting.
Aaron Stone MD – twitter
Aaron Stone MD – Plastic Surgeon Los Angeles
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