Week 13 DM

Question 1

What is diabetes in the context of surgical patients?

Answer 1

Diabetes is the most common endocrine disorder in surgical patients.

Question 2

What percentage of the U.S. population is affected by diabetes?

Answer 2

Diabetes affects more than 10.5% of the U.S. population.

Question 3

What metabolic processes does diabetes disrupt?

Answer 3

Diabetes disrupts glucose, lipid, and protein metabolism.

Question 4

What percentage of diabetic patients will undergo surgery in their lifetime?

Answer 4

25–50% of diabetic patients will undergo surgery in their lifetime.

Question 5

What is required for diabetic patients to avoid complications during surgery?

Answer 5

Precise pre-, intra-, and postoperative management is required.

Question 6

What is Type 1 Diabetes?

Answer 6

Type 1 Diabetes is characterized by autoimmune β-cell destruction leading to absolute insulin deficiency.

Question 7

What is the typical onset age for Type 1 Diabetes?

Answer 7

Type 1 Diabetes typically has an early onset during childhood or adolescence.

Question 8

What happens in the absence of insulin in Type 1 Diabetes?

Answer 8

In the absence of insulin, glucagon rises, causing serum glucose to elevate.

Question 9

What complications can arise from elevated serum glucose in Type 1 Diabetes?

Answer 9

Elevated serum glucose can trigger osmotic diuresis leading to hypovolemia.

Question 10

What is the risk associated with Type 1 Diabetes?

Answer 10

There is a high risk for ketoacidosis due to fat breakdown and ketone accumulation.

Question 11

What is Type 2 Diabetes?

Answer 11

Type 2 Diabetes involves insulin resistance and progressive β-cell failure.

Question 12

What is the most common form of diabetes?

Answer 12

Type 2 Diabetes is the most common form, accounting for approximately 90% of cases.

Question 13

What is strongly linked to Type 2 Diabetes?

Answer 13

There is a strong link between Type 2 Diabetes and obesity.

Question 14

How is Type 2 Diabetes managed?

Answer 14

Type 2 Diabetes is managed with lifestyle modification, oral agents, and/or insulin.

Question 15

What is Gestational Diabetes?

Answer 15

Gestational Diabetes occurs due to increased insulin demand during pregnancy.

Question 16

What are the risks associated with Gestational Diabetes?

Answer 16

Risks include macrosomia, intrauterine fetal demise (IUFD), and neonatal hypoglycemia.

Question 17

What is the goal glucose level for Gestational Diabetes?

Answer 17

The goal glucose level is 60–120 mg/dL.

Question 18

What are the diagnosis criteria for diabetes?

Answer 18

Diagnosis criteria include HbA1c ≥ 6.5% or fasting plasma glucose ≥ 126 mg/dL.

Question 19

What is the target glucose level for preoperative management?

Answer 19

The target glucose level is 140–180 mg/dL.

Question 20

How often should glucose be checked preoperatively?

Answer 20

Glucose should be checked every 1–2 hours.

Question 21

What medication adjustments should be made the night before surgery?

Answer 21

Decrease long-acting insulin by 20% and discontinue short-acting insulin and oral agents.

Question 22

What should be assessed for end-organ damage?

Answer 22

Coordination with an endocrinologist or PCP is essential.

Question 23

What are common complications of diabetes that affect surgery?

Answer 23

Common complications include autonomic neuropathy, stiff joint syndrome, gastroparesis, nephropathy, and atherosclerosis/CAD.

Question 24

What is the intraoperative glucose control recommendation?

Answer 24

Use IV regular insulin and maintain glucose levels <180 mg/dL.

Question 25

What anesthetic considerations should be made for diabetic patients?

Answer 25

Regional anesthesia is preferred to blunt the stress response.

Question 26

What should be monitored postoperatively?

Answer 26

Continue glucose checks every 1–2 hours and monitor for stress-induced hyperglycemia.

Question 27

What should be watched for in the postoperative period?

Answer 27

Watch for delayed emergence, PONV, hemodynamic instability, and postoperative MI.

Question 28

Which of the following is a reason for increased hemodynamic instability in the anesthetic care of diabetic patients? A. Cardiovascular autonomic neuropathy B. Increased sympathetic tone C. Hypervolemia from increased glucose levels D. Decreased plasma osmolality

Answer 28

Correct Answer: A Rationale Cardiovascular autonomic neuropathy can contribute to intraoperative hypotension, often needing supplementation with fluids or vasoactive support (Barash et al., 2017, p. 1347). This neuropathy can contribute to decreased sympathetic tone and abnormalities in the vascular baroreceptor response (Elisha et al.,2023, p. 870). Diabetic patients are predisposed to hypovolemia due to osmotic diuresis from elevated serum osmolality.

Question 29

When delivering insulin administration via IV perioperatively, what is the most common electrolyte abnormality that can occur? A. Hypercalcemia B. Hypokalemia C. Hyperkalemia D. Hyponatremia

Answer 29

Correct Answer: B Rationale The administration of intravenous insulin perioperatively can cause hypokalemia due to insulin causing an intracellular shift of potassium via its action on the Na⁺/K⁺ATPase pump (Barash et al., 2017). If an intravenous insulin infusion is administered perioperatively, the addition of small amounts of potassium chloride (20mEq) to IV fluid may be useful in avoiding this abnormality (Butterworth et al., 2023,

Question 30

Which of the following are medications that can improve gastric emptying in diabetics with gastroparesis? Select two. A. Glycopyrrolate B. Hydromorphone C. Erythromycin D. Metoclopramide

Answer 30

Correct Answer: C & D Rationale The administration of medications with prokinetic properties, such as Metoclopramide or Erythromycin, can facilitate an increase in gastric emptying (Barash et al., 2017, p.1347). Increasing gastric emptying in diabetics with gastroparesis can decrease the risk for a potential aspiration. Opioids and anticholinergics such as Hydromorphone and Glycopyrrolate decrease the level of gastric emptying.

Question 31

Which is an optimal perioperative regime for critically ill insulin-dependent patients undergoing longer procedures? A. Sliding scale bolus administration of IV insulin B. Continuous IV insulin infusion with supplemental D5W infusion C. Subcutaneous NPH insulin preoperatively & IV insulin infusion perioperatively D. Continuation of patient’s insulin pump at a basal rate

Answer 31

Correct Answer: B Rationale The utilization of a continuous insulin infusion allows for a more precise control of insulin delivery in the care of a more critically ill diabetic or during a long surgical procedure (Butterworth et al., 2023, p. 761). The administration of subcutaneous insulin can cause variability in absorption during anesthesia and insulin pump therapy should generally be discontinued during longer surgical procedures (Elisha et al., 2023, pp. 873-874). Sliding scale bolus administration can lead to drastic swings of blood glucose levels that are associated with less favorable outcomes (Elisha et al., 2023, p.873).

Question 32

Which is an optimal range of serum glucose levels to maintain perioperatively? A. 110-200 mg/dL B. 85-150 mg/dL C. 140-180 mg/dL D. 81-108 mg/dL

Answer 32

Correct Answer: C Rationale A current range of 140-180 mg/dL has been adopted by multiple medical associations in the treatment of diabetic patients within surgery. This range was researched within the NICE- SUGAR trial and evidenced to have similar outcomes to ranges that prompted more strict control of blood glucose levels (Barash et al., 2017, p. 1350). Emphasis is placed that mild hyperglycemia is preferred to hypoglycemia (Elisha et al., 2023, p. 367).

Question 33

Which of the following is not an associated end-organ complication of diabetic patients? A. Atherosclerosis B. Nephropathy C. Decreased glycosylation of tissue proteins D. Glaucoma

Answer 33

Correct Answer: C Rationale Atherosclerosis, glaucoma, and nephropathy are all associated end-organ complications that can occur with diabetes (Elisha et al., 2023, p. 760). Diabetics with chronic hyperglycemia can predispose to them to increased, not decreased, glycosylation of tissue proteins that can cause stiffening and reduced mobility of the joints (Elisha et al., 2023, p.760). Reduced mobility of the atlantooccipital joint can make intubation difficult in some diabetic patients.