Management of high-risk patients in the perioperative period -: Diabetic patients

Preoperative care: The preoperative consultation is particularly important in patients with diabetes mellitus due to the frequency and variety of degenerative complications. Cardiovascular disorders are the main cause of mortality, usually related to coronary artery disease, hypertension, left ventricular dysfunction and impaired regulatory functions caused by damage to sympathetic and parasympathetic cardiac innervation. Diabetic dysautonomic neuropathy: Sudden cardiac arrest, rhythm disorders and unstable blood pressure during the operative period are well-known complications of diabetic dysautonomic neuropathy, increasing the risk of operative morbidity and mortality in diabetics. The diagnosis is established with systolic blood pressure and heart rate, diastolic blood pressure using the grip test respiratory arrhythmia, and the Valsalva manoeuvre. In addition, the cervical spine in diabetics is stiffened by abnomal collagen structure, explaining the ten-fold increase in intubation difficulties. Gastroparesia, suggested by clinical signs, increases the risk of regurgitation and requires specific preventive measures. Finally the neurology examination may reveal sensoromotor disorders which are particularly important because nervous lesions may be exacerbated during the postoperative period. Choice of an anesthesic: The major drawback of general anesthesia is that it masks signs of hypoglycemia. Spinal anesthesia is contraindicated in case of dysautonomic neuropathy. Glucose control: Controlled insulin and glucose infusion in the perioperative period can avoid the risk of hyperosmolarity or ketoacidosis.