If You Have Diabetes, What Happened to Your BG During Surgery?

DiabeticCancerChick

I'm 54 years old with type 1 diabetes, which I've had for 27 years. On MDI using Lantus, Humalog and Humulin N (for Dawn Phenomenon). My blood sugar is very well controlled (test 15x a day, A1c 4.9%), but all of that means nothing if my blood sugar skyrockets during surgery. When I broke my ankle my basal insulin requirement nearly doubled, and I expect that to be the case when I have my BMX with TEs in mid-April. And all of that is ok while I'm conscious, but I have no idea what to expect of my blood sugar during the 5 1/2 hours I'm unconscious on the operating table. It depends on the individual, I know, but I'm just curious to know what happened to other people?

And did you have any problem being in charge of your own blood sugar instead of hospital personnel? I've heard many horror stories on that subject. And what medications (aside from steroids, which I know all about) affected your blood sugar? I haven't been hospitalized since I was 10, so I'm a little rusty!

Spookiesmom

I'm T2 on the OmniPod. Humalog only. I discussed with my BS before, TOLD him I would leave it on in a place it wouldn't be in his way.

Just went on the basal for the 23-24 hours in hospital. If you aren't pumping, is there a family member you can get to help monitor your bs? DO NOT TRUST THE NURSES TO GET IT RIGHT!!!!! They can screw you up big time, and fast.

You should be ok to do your own sticks and MDI before you leave.

mom2threeboys

DiabeticCancerChick - I'm a T1D too, MDI, 10-12 bg tests daily, etc. Been T1D for 39 years now and had my BMX surgery in 12/14. I'll relate my experience with this surgery along with some general info from prior hospitalizations and surgeries (open heart to repair a congenital heart defect, gall bladder, etc.). It is so difficult for us to lose control during surgery as well as while inpatient post op, and for good reason! I always say the hospital is the worst place for a T1D, but if you go in knowing that and are prepared I think you will have a much better outcome.

First, during surgery it is your anesthesiologist who will be responsible for maintaining your bg within a certain range. That range is usually not the tight range that you or I would like to keep it in. They should have orders (hopefully from an endocrinologist/diabetologist) which would include how frequently to test your bg while you are in surgery/post surgery (I always check mine right before being wheeled into the OR...just one last control freak moment so I can give them a heads up if I'm low/high while they are busy with all the other pre surgical activities). Those orders should also include whether insulin will be infused slowly with your IV during surgery (or injected IV if your bg is higher than certain limits) or not as well as post op instructions for the recovery room nurses for testing frequency and dosage guidelines. After you think you have your orders in place, check and check again with everyone from your surgeon to your anesthesiologist to make sure they actually see the orders in your chart.

I'm also very wary pre/post op and question everything I am being given in terms of oral and IV meds. I always ask what is in my IV in case they use dextrose or anything else that might cause an issue. My husband is with me (until they wheel me out) and is also used to questioning everyone and everything. My bmx had several unexpected surprises which left everyone scrambling (came out with a pneumothorax and chest tube). In recovery, my husband had to actually pound on a table to get everyone's attention since as soon as I was concious and could ask, he had checked my bg with my meter and it was over 300. Even though I had confirmed that orders were in place, no one could find them and without orders, no one could correct my rising bg. I had the on call pager number for the diabetology service and my husband finally called to get them involved.

Even without any major problems, the physical stress of surgery, combined with the normal emotional stress we have in this situation will make your bg rise. Couple that with a change in routine in terms of testing/injecting/eating/exercise and it is like trying to juggle 6 balls all at once.

Everyone (and I do mean everyone) in the hospital will just assume you are a type 2 diabetic. So, hospital personnel often decide it is no big deal getting injections/meals on time. In some hospitals, it is even difficult to get a carb count (instead they may only say you're on a 1200 cal diabetic diet). You probably already have easy access to a carb counting app on your phone, but if not I would be sure to load one in case this happens.

They do not like for us to give our own injections, especially when we are carb counting, so see if your doc can write an order allowing you to do so. Return the favor by logging your carbs and amount of insulin injected so they can include it in their charting. They usually allow you to do your own bg testing, but also insist on following up with their hospital bedside bg testing as well. Also, I keep my own dextrose tablets nearby to handle hypoglycemic episodes if needed so I'm not stuck with someone else's idea of what I should eat or drink to correct the hypo. I also find that at least one nurse is highly offended by the manner in which I manage my diabetes. Mind you, they could not begin to talk about insulin on board, cortisol hanging around for 24 hrs after a hypo, etc. I usually just smile, bless their hearts, and go about my business after telling them I appreciate their concern but I've been at this for 39 years, have no complications yet and intend to do it my way :-)

Do you know how long they plan for you to be inpatient or will you be allowed to go home within 24 hrs?

As spookiesmom said, do not trust the nurses to get it right and I would go a bit further and say that in general I do not trust anyone there (other than my endo or diabetology team) to get it right. I know I'm a PITA patient, but have gone into DKA twice post surgery...both times from hospital screw ups. If you have other questions, feel free to ask here or PM me.

DiabeticCancerChick

Thank you so much for both of your replies! It's such a relief to hear from people who have done it before. One thing I did know is not to trust the nurses!

I haven't heard the final word on how long my hospital stay is expected to be, but the plastic surgeon let slip that I'd be out the next day, which is good. Stress hormones are what I'm worried about most, since they are unpredictable. I'm thinking my plan will be for corrections only, half IV, half Sub-Q (for safety), with blood sugars tested every hour, and instructions written as though to a child, with numbers to reach all my doctors, who will each have been given a copy. I'll take your advice to heart about making sure there are copies everywhere. Maybe I'll tape one to my gown. Pneumothorax and chest tube... holy moly, you have seen it all. Wow.

I will check everything over and over, ask what every single substance going into my veins is. I will make sure my meter and phone/carb app is always near at hand, and I will placate and appease supercilious nurses, and expect the unexpected, however one does that!

All good advice, and I'm so grateful! Many thanks.

Spookiesmom

Oh, see if you can get a doc to order the cardiac menu. It will be low sodium, but the carb count on it will be better than what the RD, and CDEs deem " appropriate" for a diabetic.

Hospital diabetic breakfast. OJ, oatmeal, toast. Riiiigggghhhhtttt. I didn't bring enough insulin for that

mom2threeboys

DiabeticCancerChick - sounds like you have it nailed :-) You will do fine with your surgery with that great pre-op A1c.

Spookiesmom - you made me laugh about the hospital diabetic breakfast. So true! They let me order a meal tray during my 1st infusion of Kadcyla but didn't have a full menu. I chose the meal which would have the least carbs, taking chicken salad off the sandwich to eat with the lettuce and tomato, having 2 bites of fruit and then enjoying the 2 sugarfree cookies on the tray. Only problem was my bg skyrocketed and apparently the sugarfree cookies were not available so someone substituted regular cookies instead. My 2nd infusion is tomorrow and I will be bringing my own meals with me this time ;-)

Ddw79

I just had surgery this week. I am type 1 on insulin . I had to watch everyone, every step of the way. I had to advocate for what I needed to maintain reasonable bs throughout a five hour period. I was really worried because I knew they wouldn't do it right. It all works like a well oiled machine but I found that they have no clue how to handle Diabetics. Patient beware and keep advocating. Until the minute before they put me under I had to tell them what to do. Sure I made myself a pain but I came out of it ok

DiabeticCancerChick

Ddw79, this is what scares me, and I'm finding that the closer I get to surgery the more I lack confidence. But just the other day I ran into my Patient Navigator (by accident) and since I had a few questions, she asked me into her office for a chat. Somehow it came up that I have type 1 diabetes, and she informed me that there is a very sharp Diabetes Educator at the Diabetes Center connected to the hospital, and that she could help me come up with a surgical diabetes plan. What a relief! Someone who speaks both Insulin Management and Surgery.

Any plan I come up with on my own seems hopelessly complicated because there are just too many "what ifs" (how does blood sugar change after blood loss, and how would that affect my basal insulin?). Before breast cancer, I was the know-it-all diabetic scoffing at the ignorance of doctors, and now I can't wait to see the Diabetes Educator. No one ever really knows it all, and it's amazing to me how difficult it is for me to reach out for help. I'm doing it now, though, and I feel much better, and I'll post the results after my surgery in mid-April.

mom2threeboys

DiabeticCancerChick - glad you are hooked in with the diabetes educator there. In terms of blood loss, I had a double mastectomy with sentinel node biopsy on left side and my total estimated blood loss was 100ml. That represents about 2% of my total blood volume. I'm not sure how that affects your basal insulin but know that my diabetologist has me dose 1/2 my normal basal on the morning of surgery or other procedures which require sedation.

You will want to push in terms of your surgical scheduling too. So important for us to be 1st up in terms of keeping blood gluscose in control and in terms of avoiding hypos.

knmtwins

BMX with TEs hurt - hurt - hurt. Ask also about managing at home post surgery when all doped up. Make sure someone stays overnight with you at the hospital and tell them this is one of their jobs. Also, tell everyone, every time you see them. Make sure it is the last thing you tell the anesthesiologist (their job to monitor you), the BS and the PS. Tell everyone so many times they almost hate you, because, they will see your face and remember.

DiabeticCancerChick

mom2threeboys: Thanks so much for all your input. You have so much information! I'm wondering, though, did your diabetologist recommend cutting your basal in half because of the uncertainty of fasting for so long, or because the anesthesia ties the liver up the way alcohol does and changes the rate at which glucose is entering the bloodstream? I will certainly push for the earliest possible surgery (they told me 8:45am surgery... is that a "group" term or should I take that to mean my specific surgery?).

knmtwins: Points taken. Thank you!

mom2threeboys

Glad to help out! My diabetologist cuts my basal by 50% on surgery days mainly due to my hypoglycemic unawareness. I have no symptoms until my blood glucose is in the 30-40 range. I take my long acting insulin (Levemir) twice daily, so they only decrease my AM dose. The main concern is how to correct that hypo prior to surgery when we are NPO since midnight.

My diabetologist tries to compensate for the other factors (psychological stress prior to surgery will release cortisol which will hang around for 24 hrs, the anesthesia and surgery itself will cause more stress, etc). They do this by requesting periodic bg readings throughout surgery and setting the scale for correction doses of fast acting insulin during surgery and recovery.

Usually your surgery time is not a group time (although I'm seen at MDAnderson and they have several ORs in the Breast Center so when I am waiting for presurgical "stuff"although I see 3-5 of us called back as a group at the same time to get started we each go at our own time to the ORs). 8:30 is a little late for a 1st up surgery schedule (I'm used to a 7:30 surgery schedule and must arrive at 5:30 for the pre-op procedures). That could indeed be the first slot of the day for your surgery center, but I'd ask just to be sure.

After all the focus on the diabetic control issues, I have to remind myself that sometimes my diabetes takes second priority to the reason I'm having my surgery and all of the inherent issues that come with managing other systems during surgery. You are a self aware, well educated T1D and will do just fine, even without being in control a few hours. Prepare yourself as you are now with gathering info but don't stress. Just focus on being the squeeky wheel before and after surgery.

DiabeticCancerChick

mom2threeboys, you've been such a big help. Many thanks for the tips, information and just providing some much-needed perspective.

mom2threeboys

Anytime, DiabeticCancerChick! Be sure to keep us posted and you can always vent here to those who can commiserate :-)

DiabeticCancerChick

Well, it's been a while, but I did have my BMX/TE surgery in April. The Diabetes Educator got permission to accompany me to surgery (and insurance paid!), and my endocrinologist and I worked out a sliding scale insulin plan for IV insulin only. I took my normal dose of Lantus, but skipped the NPH I usually take for Dawn Effect. Circulating stress hormones from both jitters and surgical trauma were assumed, and the plan was to deal with any blood sugar elevation with IV insulin. Sounded like a good plan to me, until I met the anesthesiologist just before surgery. I had spoken to him the night before, but since an insulin management plan had been worked out, we hadn't discussed any details. Then, just before surgery, he nixed the insulin plan outlined by my endocrinologist (and the DE could say nothing) and said he would control my blood sugar with subcutaneous Regular insulin. WHAT??? He just shrugged his shoulders and said it was his call, explaining that insulin sticks to the IV tubing, throwing off any measurements. The only concession I got was that he would use SubQ Humalog instead of Regular insulin. I look back and can't believe I didn't fight harder, but everything was happening at once, Nuclear Medicine was arriving to give me a tracer injection and the plastic surgeon was drawing incision marks on my chest, and then I was being wheeled into the OR feeling great on whatever drug had just been injected.

I woke up from surgery with severe hypoglycemia, but was still able to guzzle from the Cran-Grape 6-pack I brought with me to surgery. It took over 120 grams of sugar to get my blood sugar up to 72. The nurses had no idea what to do, and were very grateful that I had brought that 6-pack. I was told that the anesthesiologist had given me 30 units of insulin. If the surgery had lasted any longer I may have been in dire straits. Once I got to my hospital room, those GEMS (also known as nurses) let me handle my blood sugar any way I saw fit, although they were the ones doing the injections, and order was soon restored.

Moral of this story: No matter what insulin management plan has been drawn up, the final word really does belong to the anesthesiologist, and my advice, which I shall henceforth take to heart without exception, is to make sure you meet with the anesthesiologist WELL before surgery day, and to involve anyone else, such as a Diabetes Educator and/or endocrinologist or PCP in order to hammer out a plan that everyone agrees on. This is such a simple thing to do. Anesthesiologists cannot understand insulin management because it's much too complicated and time consuming, so any input from those who do understand insulin management is very important.

By the way, when I suggested this to my breast surgeon, she said my endocrinologist's plan was followed almost exactly, despite looking slightly shocked when I explained that subcutaneous insulin takes at least 5 hours to run its course. She pooh-poohed the idea that the anesthesiologist had muffed because she said the dextrose bag was right at hand, and he had not had any need for it. She said it was a simple miscalculation of Lantus on my part, and that things like this happen. She had done a good job in surgery, so I ate my words, but... the GALL. That was frustrating!

So, all's well that end's well, I suppose. I'm having my reconstructive exchange surgery when I finish chemo in a few months, and I expect to have no problems at all for that one. The (new) anesthesiologist and I are going to be in complete agreement for that one.

Thanks to everyone for your input!