Towards Optimal Management of Diabetes in Surgery

343 Pages·2019·3.584 MB·English

by  Sanjeev Kelkar, Shubhangi Muley, Prakash Ambardekar

Towards Optimal
Management of
Diabetes in Surgery
Sanjeev Kelkar
Shubhangi Muley
Prakash Ambardekar
123
Towards Optimal Management of Diabetes
in Surgery
Sanjeev Kelkar • Shubhangi Muley
Prakash Ambardekar
Towards Optimal
Management of Diabetes
in Surgery
Sanjeev Kelkar Shubhangi Muley
Private Practice Senior Consultant Anesthesiologist
Pune Central India Institute of Medical Science
Maharashtra Nagpur
India Maharashtra
India
Prakash Ambardekar
Consultant, Anesthesioligist
Fortis S L Raheja Hospital
Mumbai
Maharashtra
India
ISBN 978-981-13-7704-4 ISBN 978-981-13-7705-1 (eBook)
https://doi.org/10.1007/978-981-13-7705-1
© Springer Nature Singapore Pte Ltd. 2019
This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of
the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation,
broadcasting, reproduction on microfilms or in any other physical way, and transmission or information
storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology
now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication
does not imply, even in the absence of a specific statement, that such names are exempt from the relevant
protective laws and regulations and therefore free for general use.
The publisher, the authors, and the editors are safe to assume that the advice and information in this book
are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the
editors give a warranty, expressed or implied, with respect to the material contained herein or for any
errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional
claims in published maps and institutional affiliations.
This Springer imprint is published by the registered company Springer Nature Singapore Pte Ltd.
The registered company address is: 152 Beach Road, #21-01/04 Gateway East, Singapore 189721,
Singapore
Dedicated to the general, orthopedic, and
plastic surgeons, anesthetists, and physicians
and their understudies
To the faculty in Medical Colleges
To the resident doctors and the nurses of
ICUs, operating theatres, and surgical,
medical, and gynecology wards
To our students who, over the last 20 years,
have practiced these ideas across India
And to anyone who has a need to understand
these ideas for implementation
And to all agencies and individuals who have
helped us to propagate these ideas for long.
Preface
Routine diabetes management itself has remained suboptimal in India. The mam-
moth effort put in by those who understood diabetes and willingly taught it over
hundreds of continuing medical education programs, conferences, small booklets,
and other forms of communication on diabetes has resulted in a large body of physi-
cians in India with far better understanding of diabetes. The role of the various
societies dedicated to diabetes as well as the pharmaceutical industry in this sphere
must be gratefully acknowledged. Many of these efforts have looked into develop-
ing better understanding of the perioperative management of diabetes also as part of
the overall teaching content. Even then, the perioperative situation of a patient with
diabetes remains a large gray area in modern medicine till date. Despite many
refined advancements of techniques in surgery, anesthesia, finer anesthetic drugs,
and fairly widespread understanding of diabetes management, something extra was
required to be done to make these matters also better.
The optimal management for best results in any complex situation needs an inte-
grated, collaborative, proactive approach among the three specialties—surgery,
anesthesia, and medicine. It is not only a question of their individual understanding
of diabetes. In the practical management, issues of significance and of great impor-
tance are not the medical knowledge only. These relate to logistics for better coor-
dination of them, understanding the contribution each one makes and limitations of
each of these specialties. These issues neither get discussed in any forums and even
in textbooks on diabetes nor are they addressed where these three specialists work
or are expected to work together. This volume we believe will be of great help to
make these matters also better.
Pune, Maharashtra, India Sanjeev Kelkar
Nagpur, Maharashtra, India Shubhangi Muley
Mumbai, Maharashtra, India Prakash Ambardekar
vii
Acknowledgments
In this long journey, we received support from many individuals and institutions.
Ex-vice chair of the World Diabetes Foundation, Copenhagen, Dr. Anil Kapur, and
former director of the Central India Institute of Medical Sciences, Late Dr.
G.M. Taori, were the first. Dr. Ravi Bapat, ex-HOD Surgery KEM Hospital,
Mumbai, and ex-vice chancellor of Maharashtra University of Health Sciences, has
appreciated this effort many years ago. The Association of Surgeons of India and its
various state branches, medical colleges across India, Bhilai Steel Plant, and AMRI
Hospital Kolkata were some of the institutes where we held these programs. Later,
the University of Newcastle, NSW, Australia, incorporated this program in their
educational initiatives in India; particularly helpful were Dr. Jean McPherson and
Dr. Judith Scott. The Diabetic Foot Society of India and its founder, President Dr.
Arun Bal, and other members also supported this initiative. It gave us an opportu-
nity to interact with the professional spectrum intended to be benefitted by. The
feedback we received was valuable for us to continue to improve. We are grateful to
them all. Three individuals, Mr. Mohan Naik, Mr. B.S.V. Naidu, and Mr. Aravind
Kashyap, have exerted themselves for the success of this journey.
In preparation of this volume, we are thankful to Ms. Guneet Kaur, New Delhi,
for the considerable work on transcription which made our work far easier. Mr.
V.P.M.R. Prasad from Bengaluru has been of enormous help in reference work
needed. It has lent depth to our writing. Dr. Shreerang Godbole, endocrinologist,
Pune, and Dr. Ashu Rastogi, Asst. Professor, Department of Endocrinology, PGI,
Chandigarh, have carefully gone through a few, rather intricate, chapters and cor-
rected them. The idea that it should be published as a volume was initiated by Dr.
Naren Agarwal of Springer Nature, New Delhi. We thank him for accepting the
proposal and encouraging the development and publication of this volume. We also
thank Ms. Teena Bedi and Mr. Ejaz Ahmad of Springer Nature for their assistance
and follow-up. We are grateful to all of them.
ix
About the Book
August 2019
We developed a teaching program on perioperative management of diabetes in
1995. From 1995 till 2005, we presented this in many forum and conferences, par-
ticularly to surgeons, in medical colleges across India which has continued till date
albeit more sporadically. The principle these programs followed was to build the
right perspective and establish the logic behind the themes related to the core ideas,
rather than to cram the lectures with enormous details. One forum which trained
nearly 700 medical consultants through a process of problem-based learning in
India from 2001 to 2005 was found to be particularly rewarding in emphasizing the
logic of this ill-understood area. Our efforts were highly acknowledged by all those
who listened to it. The persistent suggestion from all of them was to bring this
information in one book.
The later years witnessed an explosive growth in the much deeper understanding
of diabetes due to extensive fundamental and therapeutic research, introduction of
many newer surgical techniques which made the surgery itself quicker and safer,
investigative modalities that helped the management of the critical care situation,
and more elegant and finer equipment, techniques, and newer, safer anesthetic med-
ication. All this became available in India on a widespread scale in a short period of
time. The need to accommodate these details in a work only reinforced the desire of
attempting to write a volume on this area.
We also realized that despite the explosion of these developments, the principles
of management, and the logic behind how these new facilities should be incorpo-
rated in practice have remained the same. This has shaped the structure and the
contents of this volume. The volume thus attempts to achieve the following:
The first half of the book purposely focuses on the critical care aspects of diabetes
management in surgical setting. In doing that, we have emphasized the need to shift
the focus of control of diabetes and other abnormalities arising there from to the resi-
dents and the ICU or the ward nurses. Thus, the first chapter addresses to empower
these doctors to manage these situations primarily. For that, we have used most of the
situations they routinely confront, the reasoning behind why they develop, and, as a
fallout, the measures, monitoring, and precautions they should take. We have also
pointed out the huge practical benefits that result out of this. It also addresses the
consultants in all the above branches and how to support the management from
behind without getting in to minute-to-minute management.
xi
xii About the Book
The critical surgical (and medical) care in diabetes is invariably accompanied by
diabetic ketoacidosis and hyperosmolar states, the most difficult to control. This
chapter extends the glucose management in more complete management of all other
abnormalities. It also indicates the fundamental relation of the surgical state, giving
rise to these two states and the intriguing aspects related to it.
The third chapter builds upon this understanding in emergency major situations
and its management. The emphasis now changes from practical management to the
understanding of the more fundamental pathological dysfunctions of all the organ
systems which are potentially dangerous to survival. It also discusses the barriers in
taking such a patient up for surgery early, the most crucial issue in this area.
Logically, the fourth and fifth chapters enter in the discussion of intra- and post-
operative management, followed by the discussion of the single factor of hypogly-
cemia and how it keeps the routine or critical surgical and diabetes management
suboptimal in perioperative situations.
The next chapter gives a detailed expose of the numerous issues that arise in the
elective, routine surgical situations.
The number of surgical options to rectify different disorders has increased. Even
if they are elective in nature, there is a need to have a better understanding of the
pathophysiology, organ effects, and its perioperative and longer term risks, we have
grouped all of them in two chapters of Special Surgical Situations. This chapter thus
goes in greater depth of theory but much greater degree of management as well.
Two areas have been given special importance since these are generally not covered
in detail in discourses or in the textbooks. The first is the gestational diabetes. The
professional attention in diagnosis and good management needs a boost since it is
related also to the primordial and primary prevention of diabetes in the future gen-
erations. The numbers are also rising, and a different specialty of gynecology now
works with the physicians and anesthetists.
The second emphasis is on the regional anesthesia in diabetic foot and such other
local surgical procedures. We believe that its importance lies in its sheer high preva-
lence, highly suboptimal conditions in which the patients present, difficulties in
taking them up for surgery and devastating consequences both on life and economy
as no other condition in diabetes does.
The other need we felt strongly was to give an in-depth knowledge of the diabe-
tes as such. Without that, the discussions on practical management with its reason-
ing, we felt, would not be complete. Secondly, the later stages of perioperative
management, at discharge and beyond also, must see the optimal understanding of
it. Hence, we have written detailed chapters on insulin physiology with its actions,
its pharmacodynamics, and its pharmacokinetics. The same has been applied to
other drugs used in diabetes, comorbid conditions, and their drug-to-drug
interactions.
The knowledge of the deeper understanding of the pathological basis of diabetes
was scattered throughout the volume. There were many aspects which was essential
to elaborate. In order not to disturb the flow of the discussion, we did not include
them but decided to present them as a separate chapter titled Metabolic Havoc of
Uncontrolled Diabetes, which is profound in theory.
About the Book xiii
The same difficulty arose in including several aspects of care. Many of them are
smaller areas. Some are areas where a conflict is apparent. In other places, the his-
torical understanding of some of the changes that have occurred was required to
build the full care perspective. The Commonly Asked Questions collected together
in the last chapter fall in these categories. They are as instructive as the metabolic
havoc. On the whole, there might be a miniscule minority of issues we may not have
touched.
The authors have a combined clinical and teaching experience of nearly 100
years. We have some insight in the exact needs of the doctors. Therefore, lastly, our
endeavor is geared to improve the in-depth understanding by identifying the learn-
ing gaps and attempts to develop the habit of critical clinical reasoning which pres-
ently is rather dim. We sincerely hope the volume will be of help and will be
welcomed by the medical fraternity.
Sanjeev Kelkar
Shubhangi Muley
Prakash Ambardekar