Table of content
• Abstract
• Introduction
• Methods
• Results
• Synopsis of literature
• Discussion
• References
PERI-OPERATIVE MANAGEMENT OF DIABETES 2
Abstract
The incidence of diabetes is rising rapidly over time. Patients with diabetes are at higher
risk of developing post-operative complications such as hyperglycemia or hypoglycemia which
in turn contribute to increased morbidity and mortality and length of hospital stay in patient with
diabetes undergoing surgery. Therefore, it is extremely important for nurses to take vigilant care
of patients with diabetes undergoing surgery. This paper will describe the guidelines of peri-
operative management of patient with diabetes and why it is important for nurses to follow these
guidelines. Moreover, observations at clinical placements as compared to the findings in peer
reviewed research articles will also be discussed in this paper.
Introduction
Diabetes is a metabolic disorder in which blood glucose levels remain high above normal.
Patients with diabetes undergoing surgery may have specific needs, particularly in relation to
blood glucose control and healthcare professionals such as nurses need to be able to assess and
manage these individuals to ensure optimum surgical outcomes. Moreover, the metabolic impact
of surgery, pre-op fasting and disruption in insulin therapy contribute to poor glycemic control
which in turn leads to increased mortality and morbidity. To deal with this issue, it is always
necessary for nurses to follow guidelines for perioperative management of diabetes for the
diabetic patients. However, the problem is that most nurses and other professionals are likely to
overlook these guidelines, thus placing the patient at a health risk.
PERI-OPERATIVE MANAGEMENT OF DIABETES 3
Methods
This study involved the use of national database CINAHL Complete, which is available
publically and through Australian Catholic University library. This study was conducted by
gathering the results from medical research particularly from peer-reviewed journal articles.
Results
The results indicate that the level of awareness among nurses and other professionals
such as anesthetists with regard to perioperative guidelines has increased over the last three
decades.
Synopsis of literature
According to Marchant et al (2009), patients with uncontrolled diabetes are at greater risk
of developing post-operative complications when compared with patients with controlled
diabetes. Merchant et al (2009) suggested that healthcare professionals should monitor blood
glucose levels pre-operatively as it is independent predictor of morbidity and mortality in patient
with diabetes undergoing surgery. However, they also recommend healthcare professionals to
monitor HbA1c levels to assess the risk of post-operative complications. Moreover, HbA1c level
less than 7% is associated with lower risk of post-operative complications (Kerry, Scott &
Rayman, 2013).
On the other hand, Holt (2012) reviewed the available data on pre and post-operative
needs of patient with diabetes. He stated that it is very crucial for nurses to conduct appropriate
pre-operative assessment of patient with diabetes at the earliest opportunity. However, not only
blood glucose levels or Hb1Ac levels should be assessed, but also a complete patient history and
PERI-OPERATIVE MANAGEMENT OF DIABETES 4
examination should be carried out as further backed up by Dhinsa, Khan & Puri (2010). This
allows time to assess adequacy of patient’s control of their diabetes and instigate action if
needed. This minimizes the risk of post-operative complications such as hyperglycemia. In
addition, Holt (2012) also explored that patients with poorly controlled diabetes experience more
post-operative pain as compared to patients with well controlled diabetes.
Dhinsa, Khan & Puri (2010) explored the clinical guidelines for peri-operative
management of patient with diabetes in their article. They mainly discuss the post-operative
complications of patient with diabetes and nursing interventions. According to Dhinsa, Khan &
Puri (2010), it should be nurse’s first priority to keep patient pain-free as to minimize the effect
of body’s stress response to pain on blood glucose levels. This is further supported by Holt
(2012) who argued that body’s stress response inhibit insulin secretion as well as increase insulin
resistance. Nevertheless, stress due to surgical interventions not only raise the blood glucose
levels in patient diagnosed with diabetes but also in patients without pre-operative diagnosis of
diabetes as stated by Dhinsa, Khan & Puri (2010).
Dhatariya (2012) explains some clinical guidelines for patients with diabetes. He suggests
it is preferable to place patients with diabetes early on theatre list to reduce the patient’s fasting
time. This is because pre-operative fasting and discontinuation of oral hypoglycemic agents can
cause hypoglycemia. It is also recommended that elective surgery should be postponed if pre-
operative glycemic control is poor (Dhatariya, 2012). Dhatariya (2012) also argues that it is
necessary for the nurses to work with the patient and the patient’s family to help them with
adhering to the part of the preoperative guidelines that are beyond the nurse’s domain. These
include the pre-surgery fasting (Learning Zone, 2012).
PERI-OPERATIVE MANAGEMENT OF DIABETES 5
Discussion
During my clinical placements, I noticed that not all patients are tested for diabetes
before surgery. This is a major issue as not all patients are aware of whether they have diabetes
or not. In addition to this, I have observed that despite the fact that patients whose diabetic status
is already known, the nurses are likely to overlook the symptoms of hyperglycemia such as
itching skin, fruity breath, and confusion. It is difficult to identify usual warning signs of poor
glycemic control while patient is unconscious which is potentially life-threatening and the nurses
therefore need to do this before the patient is in sedated. Furthermore, when measuring blood
glucose levels, the patient’s type of diabetes and type of antidiabetic medication they are on were
overlooked, thus placing the patient at a much higher risk. I have seen that blood glucose checks
are not performed while patient is in operation theatre, however, which goes against he
guidelines as discussed by Campbell (2011). Discharge education for patient with diabetes plays
an important role in their well-being post-operatively such as teaching patient about signs and
symptoms of hyperglycemia, wound infection and wound non-healing. However, I have seen
very few nurses in post anesthesia care unit giving discharge education to patients with diabetes
which is also argued by Rutan and Sommers (2012). The other issue that is observable at the
clinical placements is the fact that the different healthcare personnel are fully aware of the
recommended guidelines. Other staff such as the anesthetists who also play an important role in
the surgery process are also likely to be ignorant of the most up-to-date guidelines for
preoperative care for patients with diabetes. All these factors work together to bring in a problem
that can affect the post surgery results.
In this regard, even if the surgical team is able to fully adhere to the peri-operative care
from the time that the patient is at the hospital, they are not able to do the same for the patient
PERI-OPERATIVE MANAGEMENT OF DIABETES 6
when he or she is not at the hospital. This includes the pre admission time where pre surgery
fating is part of the peri-operative care. To implement the peri-operative care in a comprehensive
manner, some aspects of the hospital’s operations will need some changes. First, there is a need
for a better support system to help the patient and the patient’s family with regard to the part of
the preoperative care that they are responsible for, such as pre surgery fasting. Secondly, the
nurses need to update their knowledge of the full process of preoperative care. Thirdly, the
hospitals should develop policies which will make it easier for healthcare personnel to identify
surgery patients with diabetes and who do not already know they have diabetes.
References
Campbell, A. (2011). Pre-Operative Fasting Guideunes For Children Having Day Surgery.
Nursing Ohildren And Young People, 23, 4 , pp. 14-21.
Dhinsa, B., Khan, W., & Puri, A. (2010). Management of the patient with diabetes in the
perioperative period. Journal Of Perioperative Practice, 20(10), 364-367.
Rutan, L., & Sommers, K. (2012). Hyperglycemia as a risk factor in the perioperative patient.
AORN Journal, 95(3), 352-363. doi:10.1016/j.aorn.2011.06.010
Dhatariya, K. (2012). Perioperative management of adults with diabetes: why do we need
guidance?. British Journal Of Hospital Medicine (17508460), 73(7), 366-367.
PERI-OPERATIVE MANAGEMENT OF DIABETES 7
Holt, P. (2012). Pre and post-operative needs of patients with diabetes. Nursing Standard,
26(50), 50-56.
Kerry, C. S., Scott, A., & Rayman, G. (2013). Daily temporal patterns of hypoglycaemia in
hospitalized people may reveal potentially correctable factors. Diabetic Medicine, 30, 12 , 27-38.
Learning Zone. (2012). Pre and post-operative needs of patients with diabetes. Nursing Standard.
26, 50 , pp. 50-56.
Marchant, H. et al. (2009). The Impact of Glycémie Control and Diabetes Mellitus on
Perioperative Outcomes After Total Joint Arthroplasty. The Journal Of Bone And Joint Surgery,
Incorporated, 97, 1 , pp. 1621-1629.
