SPECIAL SITUATIONS

Surgery

Diabetic patients should be screened in advance for complications (e.g. cardiovascular or renal disease, autonomic neuropathy) which increase the surgical risk. Smooth control of diabetes minimizes the risk of infection and balances the catabolic response to anaesthesia and surgery. Treatment should be intensified in poorly controlled diabetics (HbA1C > 70 mmol/mol or random blood glucose > 11 mmol/L) prior to surgery or patients admitted the night before for an insulin sliding scale if surgery is urgent, e.g. cancer. Where possible diabetic patients should be first on the operating list and a blood glucose of 6-11 mmol/L maintained during the perioperative period. Hypogly-caemia developing perioperatively is treated as previously described (p. 675).

Major surgery (i.e. having a general anaesthesic):

■ Normal subcutaneous insulin doses are given the day before surgery.

■ On the day of surgery omit morning insulin or oral hypoglycaemic (except stop metformin 24 hours before as risk of lactic acidosis). A glucose/ insulin/potassium infusion is started at 08:00 am with hourly glucose monitoring. A standard combination is 16 U of soluble insulin with 10 mmol of KCL in 500 ml of 10% glucose infused at 100 mL/h - the insulin can also be administered separately via a syringe pump.

■ The insulin dose is adjusted by +/- 4 U if blood sugars are persistently high or low respectively and potassium also adjusted depending on serum measurements.

■ Postoperatively the infusion is maintained until the patient is eating and drinking normally. The normal insulin regimen is restarted with a 30 minute overlap with the infusion.

Minor surgery (e.g. endoscopy):

Insulin-treated patients On the day of surgery omit morning insulin (unless long-acting insulin in which case give two-thirds dose). Check blood glucose every 2 hours. Once the patient is eating and drinking after procedure give two-thirds of normal morning insulin (if twice a day regimen of insulin nor-mally given) or normal dose of rapidly acting insulin (if four times a day regimen normally given) and tea-time insulin as normal.

Tablet-controlled diabetes Omit diabetes medication on the morning of procedure. Check blood glucose 2-hourly. Restart oral hypoglycaemics with first meal.

Pregnancy and diabetes

Poorly controlled diabetes at the time of conception and during pregnancy is associated with congenital malformations, macrosomia (large babies), hydramnios, pre-eclampsia and intrauterine death. In the neonatal period there is an increased risk of hyaline membrane disease and neonatal hypoglycaemia (unlike insulin, maternal glucose crosses the placenta and causes hypersecretion of insulin from the fetal islets, which continues when the umbilical cord is cut). Meticulous control of blood glucose levels (assessed by daily home blood testing before and 2 hours after meals) achieves results comparable to those with non-diabetic pregnancies.

Gestational diabetes is diabetes that develops in the course of pregnancy and remits following delivery. Treatment is with diet in the first instance, but most patients require insulin cover during pregnancy. It is likely to recur in subsequent pregnancies, and diabetes may develop later in life.

Acutely ill hospital inpatients

Acutely ill diabetic patients are susceptible to hyperglycaemia because of increased release of counter-regulatory stress hormones (adrenaline, cortisol and growth hormone), physical inactivity and possibly an alteration in diet. Good glucose control reduces mortality in acute myocardial infarction, stroke and critically ill patients on ITU. Metformin should not be given to an ill patient in hospital because of the risk of lactic acidosis. Patients who are not eating are managed with an insulin sliding scale (Table 15.8) with a target blood glucose of 4-9 mmol/L (4-7 in stroke and MI).

Unstable diabetes

This is used to describe patients with recurrent ketoacidosis and/or recurrent hypoglycaemic coma. Of these, the largest group is made up of those who experience recurrent severe hypoglycaemia.

Ebook Essentials of Kumar and Clark's Clinical Medicine, 5e

1. Ethics and communication

Ethics and communication

2. Infectious diseases

Infectious diseases

3. Gastroenterology and nutrition

Gastroenterology and nutrition

4. Liver, biliary tract and pancreatic disease

Liver, biliary tract and pancreatic disease
LIVER BIOCHEMISTRY AND LIVER FUNCTION TESTS
SYMPTOMS AND SIGNS OF LIVER DISEASE
JAUNDICE
HEPATITIS
NON - ALCOHOLIC FATTY LIVER DISEASE (NAFLD)
CIRRHOSIS
COMPLICATIONS AND EFFECTS OF CIRRHOSIS
LIVER TRANSPLANTATION
TYPES OF CHRONIC LIVER DISEASE AND CIRRHOSIS
PRIMARY SCLEROSING CHOLANGITIS
BUDD - CHIARI SYNDROME
LIVER ABSCESS
LIVER DISEASE IN PREGNANCY
LIVER TUMOURS
GALLSTONES
THE PANCREAS
CARCINOMA OF THE PANCREAS
NEUROENDOCRINE TUMOURS OF THE PANCREAS

5. Haematological disease

Haematological disease
ANAEMIA
Assessment and treatment of suspected neutropenic sepsis
HAEMOLYTIC ANAEMIA
INHERITED HAEMOLYTIC ANAEMIAS
ACQUIRED HAEMOLYTIC ANAEMIA
MYELOPROLIFERATIVE DISORDERS
THE SPLEEN
BLOOD TRANSFUSION
THE WHITE CELL
HAEMOSTASIS AND THROMBOSIS
THROMBOSIS
THERAPEUTICS

6. Malignant disease

Malignant disease
MYELOABLATIVE THERAPY AND HAEMOPOIETIC STEM CELL TRANSPLANTATION
THE LYMPHOMAS
THE PARAPROTEINAEMIAS
PALLIATIVE MEDICINE AND SYMPTOM CONTROL

7. Rheumatology

Rheumatology
COMMON INVESTIGATIONS IN MUSCULOSKELETAL DISEASE
COMMON REGIONAL MUSCULOSKELETAL PROBLEMS
BACK PAIN
OSTEOARTHRITIS
INFLAMMATORY ARTHRITIS
THE SERONEGATIVE SPONDYLOARTHROPATHIES
Clinical features, Investigations
INFECTION OF JOINTS AND BONES
AUTOIMMUNE RHEUMATIC DISEASES
SYSTEMIC INFLAMMATORY VASCULITIS
DISEASES OF BONE
THERAPEUTICS

8. Water, electrolytes and acid–base balance

WATER AND ELECTROLYTE REQUIREMENTS
BODY FLUID COMPARTMENTS
REGULATION OF BODY FLUID HOMEOSTASIS
PLASMA OSMOLALITY AND DISORDERS OF SODIUM REGULATION
DISORDERS OF POTASSIUM REGULATION
DISORDERS OF MAGNESIUM REGULATION
DISORDERS OF ACID - BASE BALANCE
THERAPEUTICS

9. Renal disease

Renal disease
INVESTIGATION OF RENAL DISEASE
GLOMERULAR DISEASES
NEPHROTIC SYNDROME
URINARY TRACT INFECTION
TUBULOINTERSTITIAL NEPHRITIS
HYPERTENSION AND THE KIDNEY
RENAL CALCULI AND NEPHROCALCINOSIS
URINARY TRACT OBSTRUCTION
ACUTE RENAL FAILURE/ACUTE KIDNEY INJURY
CHRONIC KIDNEY DISEASE
RENAL REPLACEMENT THERAPY
CYSTIC RENAL DISEASE
TUMOURS OF THE KIDNEY AND GENITOURINARY TRACT
DISEASES OF THE PROSTATE GLAND
TESTICULAR TUMOUR
URINARY INCONTINENCE

10. Cardiovascular disease

COMMON PRESENTING SYMPTOMS OF HEART DISEASE
INVESTIGATIONS IN CARDIAC DISEASE
CARDIAC ARRHYTHMIAS
HEART FAILURE
ISCHAEMIC HEART DISEASE
RHEUMATIC FEVER
VALVULAR HEART DISEASE
PULMONARY HEART DISEASE
MYOCARDIAL DISEASE
CARDIOMYOPATHY
PERICARDIAL DISEASE
SYSTEMIC HYPERTENSION
ARTERIAL AND VENOUS DISEASE
ELECTRICAL CARDIOVERSION
DRUGS FOR ARRHYTHMIAS
DRUGS FOR HEART FAILURE
DRUGS AFFECTING THE RENIN - ANGIOTENSIN SYSTEM
NITRATES, CALCIUM - CHANNEL BLOCKERS AND POTASSIUM - CHANNEL ACTIVATORS

11. Respiratory disease


Respiratory disease
TUBERCULOSISnd
DIFFUSE DISEASES OF THE LUNG PARENCHYMA
OCCUPATIONAL LUNG DISEASE
CARCINOMA OF THE LUNG
DISEASES OF THE CHEST WALL AND PLEURA
DISORDERS OF THE DIAPHRAGM

12. Intensive care medicine

Intensive care medicine

13. Drug therapy, poisoning, and alcohol misuse

Drug therapy, poisoning, and alcohol misuse

14. Endocrine disease

Endocrine disease
PITUITARY HYPERSECRETION SYNDROMES
THE THYROID AXIS
MALE REPRODUCTION AND SEX
FEMALE REPRODUCTION AND SEX
THE GLUCOCORTICOID AXIS
THE THIRST AXIS
DISORDERS OF CALCIUM METABOLISM
DISORDERS OF PHOSPHATE CONCENTRATION
ENDOCRINOLOGY OF BLOOD PRESSURE CONTROL
DISORDERS OF TEMPERATURE REGULATION
THERAPEUTICS

15. Diabetes mellitus and other disorders of metabolism

DIABETES MELLITUS
DIABETIC METABOLIC EMERGENCIES
COMPLICATIONS OF DIABETES
SPECIAL SITUATIONS
HYPOGLYCAEMIA IN THE NON - DIABETIC
DISORDERS OF LIPID METABOLISM
THE PORPHYRIAS

16. The special senses

THE EAR
THE NOSE AND NASAL CAVITY
THE THROAT
THE EYE

17. Neurology

COMMON NEUROLOGICAL SYMPTOMS
COORDINATION OF MOVEMENT
THE CRANIAL NERVES
COMMON INVESTIGATIONS IN NEUROLOGICAL DISEASE
UNCONSCIOUSNESS AND COMA
STROKE AND CEREBROVASCULAR DISEASE
EPILEPSY AND LOSS OF CONSCIOUSNESS
NERVOUS SYSTEM INFECTION AND INFLAMMATION
HYDROCEPHALUS
HEADACHE, MIGRAINE AND FACIAL PAIN
SPINAL CORD DISEASE
DEGENERATIVE NEURONAL DISEASES
DISEASES OF THE PERIPHERAL NERVES
MUSCLE DISEASES
MYOTONIAS
DELIRIUM
THERAPEUTICS

18. Dermatology

Dermatology

KEYWORD : Phác Đồ Chữa Bệnh, Bệnh Viện Bạch Mai, Từ Dũ , 115, Bình Dân, Chấn thương chỉnh hình, Chợ Rẫy, Đại học Y Dược, Nhân Dân Gia Định, Hoàn Mỹ, Viện Pasteur, Nhi Đồng Ung bướu, Quân Đội 103, 108,Phụ Sản Trung Ương, Bộ Y Tế,Phòng Khám, Hà Nội, Hải Dương, Thái Bình, Hồ Chí Minh, Sài Gòn, Đà Nẵng, Huế, Vinh, Đồng Nai, Bình Dương, Hải Phòng, Quảng Ninh, Hiệu Quả Cao, Chữa Tốt, Khỏi Bệnh, Là Gì, Nguyên Nhân, Triệu Chứng, Ăn Uống, Cách Chữa, Bài Thuốc
Thông Tin Trên Web Là Tài Liệu Lưu Hành Nội Bộ Cho Các Bạn Sinh Viên - Y, Bác Sĩ Tham Khảo : Liên Hệ : Maikhanhdu@gmail.com