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Barker et al. | Guidelines on peri-operative management of diabetes Anaesthesia 2015 with diabetes and does not contribute to clinically significant hyperglycaemia [23]. Fluid management for patients requiring a VRIII The aim is to provide glucose as a substrate to prevent proteolysis, lipolysis and ketogenesis, as well as to optimise intravascular volume status and maintain plasma electrolytes within the normal range. It is important to avoid iatrogenic hyponatraemia from the administration of hypotonic solutions. Glucose 5% solution should be avoided. Use of glucose 4% in 0.18% saline can be associated with hyponatraemia. The substrate solution to be used should be based on the patient’s current electrolyte concentrations. While there is no clear evidence that one type of balanced crystalloid fluid is better than another, halfstrength ‘normal’ saline combined with glucose is, theoretically, a reasonable compromise to achieve these aims. Thus, the initial fluid should be glucose 5% in saline 0.45% pre-mixed with either potassium chloride 0.15% (20 mmol.l 1 ) or potassium chloride 0.3% (40 mmol.l 1 ), depending on the presence of hypokalaemia (< 3.5 mmol.l 1 ). The Working Party recognises that these fluids may not be available in all institutions. It is our view that they should be made available in all areas where patients with diabetes will be managed. (Hospitals caring for children will usually have these solutions already available for general paediatric use). Fluid should be administered at the rate that is appropriate for the patient’s usual maintenance requirements – usually 25–50 ml.kg 1 .day 1 (approximately 83 ml.h 1 for a 70-kg patient) [24]. Very occasionally, the patient may develop hyponatraemia without signs of fluid overload. In these circumstances, it is acceptable to prescribe one of the following solutions as the substrate solution: glucose 5% in saline 0.9% with pre-mixed potassium chloride 0.15% (20 mmol.l 1 ); or glucose 5% in saline 0.9% with premixed potassium chloride 0.3% (40 mmol.l 1 ). (Again, hospitals caring for children will usually have these solutions available). Additional Hartmann’s solution or another balanced isotonic crystalloid solution should be used to optimise intravascular volume status. Fluid management for patients not requiring a VRIII The aim is to avoid glucose-containing solutions unless the blood glucose is low. It is important to avoid hyperchloraemic metabolic acidosis; Hartmann’s solution should be administered to optimise the intravascular volume status. If the patient requires prolonged postoperative fluids (> 24 h), a VRIII should be considered and glucose 5% in saline 0.45% with pre-mixed potassium chloride given as above. Returning to ‘normal’ (pre-operative) medication and diet The postoperative blood glucose management plan, and any alterations to existing medications, should be clearly communicated to ward staff. Patients with diabetes should be involved in planning their postoperative care. If subcutaneous insulin is required in insulin-na€ıve patients, or the type of insulin or the time it is to be given is to change, the specialist diabetes team should be contacted for advice. Transferring from a VRIII back to oral treatment or subcutaneous insulin If the patient has type-1 diabetes and a VRIII has been used, it must be continued for 30–60 min after the patient has had their subcutaneous insulin (see below). Premature discontinuation is associated with iatrogenic DKA. Restarting oral hypoglycaemic medication Oral hypoglycaemic agents should be recommenced at pre-operative doses once the patient is ready to eat and drink; withholding or reduction in sulphonylureas may be required if the food intake is likely to be reduced. Metformin should only be restarted if the estimated glomerular filtration rate exceeds 50 ml.min 1 .1.73 m 2 [25]. Restarting subcutaneous insulin for patients already established on insulin Conversion to subcutaneous insulin should commence once the patient is able to eat and drink without nausea or vomiting. The pre-surgical regimen should be restarted, but may require adjustment because the insulin requirement may change as a result of postoperative stress, infection or altered food intake. The diabetes spe- © 2015 The Authors. Anaesthesia published by John Wiley & Sons Ltd on behalf of Association of Anaesthetists of Great Britain and Ireland 7
Anaesthesia 2015 Barker et al. | Guidelines on peri-operative management of diabetes cialist team should be consulted if the blood glucose levels are outside the acceptable range (6–12 mmol.l 1 ) or if a change in diabetes management is required. The transition from intravenous to subcutaneous insulin should take place when the next meal-related subcutaneous insulin dose is due, for example with breakfast or lunch. For the patient on basal and bolus insulin There should be an overlap between the end of the VRIII and the first injection of subcutaneous insulin, which should be given with a meal and the intravenous insulin and fluids discontinued 30-60 min later. If the patient was previously on a long-acting insulin analogue such as Lantus â , Levemir â or Tresbia â , this should have been continued and thus the only action should be to restart his/her usual rapid-acting insulin at the next meal as outlined above. If the basal insulin was stopped, the insulin infusion should be continued until a background insulin has been given. For the patient on a twice-daily, fixed-mix regimen The insulin should be re-introduced before breakfast or before the evening meal, and not at any other time. The VRIII should be maintained for 30-60 min after the subcutaneous insulin has been given. For the patient on a continuous subcutaneous insulin infusion The subcutaneous insulin infusion should be recommenced at the patient’s normal basal rate; the VRIII should be continued until the next meal bolus has been given. The subcutaneous insulin infusions should not be re-started at bedtime. Resumption of normal diet The key to successful management of the surgical patient with diabetes is resumption of his/her usual diet. This allows resumption of normal diabetes medication. Hospital discharge is only feasible once the patient has resumed eating and drinking. Other anaesthetic considerations Use of dexamethasone Dexamethasone can lead to hyperglycaemia and should be used with caution in patients with diabetes [26]. If it is decided that the possible benefits of earlier resumption of normal diet outweigh the disadvantages of hyperglycaemia, it should be ensured that the CBG is measured hourly for at least 4 h after administration. Use of regional anaesthesia Local anaesthetic techniques, when used as the sole anaesthetic, reduce the risk of postoperative nausea and vomiting. Furthermore, when used as part of the multimodal technique in general anaesthesia, they have opioid-sparing actions, with resultant reduction of opioid-related side-effects. However, evidence suggests that patients with diabetes are more prone to epidural abscesses and haemodynamic instability after central neuraxial blockade (in patients with an autonomic neuropathy), and, possibly, increased risk of neuropathy after peripheral nerve blocks [27–29]. Enhanced recovery after surgery Enhanced recovery of patients undergoing surgery utilises several strategies to promote earlier resumption of normal diet, earlier mobilisation, and reduced length of stay [30]. This has particular relevance for patients with diabetes as it promotes eating and drinking (reducing the risk of iatrogenic harm from a VRIII), and by promoting earlier discharge. Use of oral carbohydrate loading drinks Carbohydrate loading may compromise blood glucose control and should not be used in patients with insulin-treated diabetes who are likely to have a short period of fasting. There is some evidence that oral carbohydrate loading may be safe in patients with type-2 diabetes [31], and if a VRIII is to be used in any case there is no reason to withhold oral carbohydrate loading drinks in any patient with diabetes. Patients with diabetes requiring emergency surgery There are three ways of managing diabetes in the patient requiring emergency surgery: 1 Modification of normal medication. This is only possible if the patient is physiologically well and is being operated on a scheduled list, for example a 8 © 2015 The Authors. Anaesthesia published by John Wiley & Sons Ltd on behalf of Association of Anaesthetists of Great Britain and Ireland
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Recommendations for the Safe Transf
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CONTENTS Section I Summary and Reco
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SECTION II - BACKGROUND In 1996 the
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SECTION IV - ORGANISATION AND COMMU
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SECTION V - STAFFING REQUIREMENTS A
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A p p ropriate re s p i ra t o ry s
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SECTION VII - THE TRANSFER The tran
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SECTION VIII - EQUIPMENT AND DRUGS
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SECTION IX - EDUCATION AND TRAINING
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SECTION X - RESOURCE IMPLICATIONS F
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APPENDIX I INDICATIONS FOR INTUBATI
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APPENDIX III ADDITIONAL INFORMATION
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AAGBI SAFETY GUIDELINE Suspected An
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GUIDELINES Suspected Anaphylactic R
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Suspected anaphylactic reactions as
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Storage of Drugs in Anaesthetic Roo
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Storage of Drugs in Anaesthetic Roo
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This guideline was originally publi
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Anaesthesia 2016, 71, 1503 Correcti
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Membership of the working party Dr
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1. Summary 1.1 Safety, quality and
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3.4 The Trust - Medical Devices Man
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equipment officer is encouraged to
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EU procurement thresholds Threshold
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When negotiating a purchasing agree
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Third party servicing is another op
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Where new equipment is purchased th
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available from www.hse.gov.uk 14.4
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Methods to estimate/establish publi
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Recommendations The WP recommends:
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Anaesthesia, 2007, 62, pages 1199-1
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OPTION 3 - PRESUMED CONSENT. ‘Pre
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Power of Attorney) while requiring
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Needle-stick injury and HIV testing
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Management of hypertension before e
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AAGBI Safety Guideline Management o
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This process may require many telep
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Section 6 Accompanying the patient
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Contents ❚ Foreword 4 Introductio
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Introduction ❚ The Good Anaesthet
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