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410 Cardio Diabetes Medicine 2017

DM Management in Special Situations –

Post Renal Transplant and Post CABG

Prof. (Dr.) Sandeep Bansal, Dr. Preeti Gupta
Vardhaman Mahavir Medical College and Safdarjung Hospital,

Introduction Consequences (immediate and long term)
The diabetic patient faces additional hazards when • Dehydration and hemodynamic instability(os-
undergoing surgery as compared to the non-diabetic motic diuresis)
population. These are as follows: • Negative nitrogen balance
• Loss of lean body mass
1. Hyperglycemia and possible ketoacidosis caused
by the body’s stress response to surgery • Impaired wound healing
• Reduced resistance to infection
2. Hypoglycemia due to peri-operative fasting wors- • Loss of adipose tissue and energy reserve(lip-
ened by the prolonged action of certain long acting olysis)
insulins or oral hypoglycemic agents. • Deficiency of essential amino acids, vitaminsand
3. Peri-operative complications that are increased minerals.
by diabetes, e.g. incidence of wound infections and Table 1: Endocrine and Metabolic Responseto Sur-
myocardial infarctions gery in Diabetic Patients.1

Metabolic Response to Surgery DM management Post CABG-
Surgery causes a prototypical stress response in a Glucose containing fluids are used to prime the by-
diabetic. There is a combination of anti-insulin ef- pass pumps. There are unusual degrees of trauma
fects of surgical stress and direct catabolic effects to tissues during bypass surgeries and inotropes
of stress hormones. with catecholamine like action are often used. This,
along with the hypothermia induced per-operatively
Endocrine increases insulin resistance. Thus, very high dosage
• Increased secretion of counter regulatoryhor- of insulin may be required perioperatively in patients
mones: undergoing open-heart surgeries. 2, 3 However, with
Catecholamines; glucagon; cortisol;growth newer surgical techniques, like ‘beating heart sur-
hormone gery’ for CABG the surgical stress associated with
• Decreased insulin secretion (Loss of anticata- cardiac surgery is coming down.
boliceffect)
Decreased insulin action (insulinresistance)
The IV insulin infusion can be set up by two
Metabolic methods:-
• Hyperglycemia
• Decreased glucose disposal (utilization) I.Glucose-potassium-insulin or GKI Regimen: The GKI
• Increased glucose production (secondary togly- drip or the glucose potassium insulin drip also known
cogenolysis and neoglucogenesis) as Alberti regimen. It involves starting an i.v. infusion
• Increased protein catabolism of a pre-mixed cocktail of 10% glucose solution and
• Increased lipolysis and ketogenesis (variable) 10 mmol of potassium chloride and 15 units of sol-
• Increased metabolic rate and catabolism uble insulin, which is to be infused at the rate of
100ml/hour. The GKI system assumes that the pa-
4

GCDC 2017