Insulin pump periop Mx

43-year-old lady for consideration of laparoscopy for investigation of endometriosis, pelvic pain, and menorrhagia

Issues:

  • Type 1 DM, good glycaemic control
  • IHD
    • STEMI in 2020. Post-partum.
    • LAD stenosis 90%. PCI to LAD,
    • DAPT for 12 months.
  • HFrEF with global hypokinesis
    • Admission post PCI with APO but now stable on medical therapy
    • Excellent exercise tolerance
    • Regular cardiologist review
  • MH
    • confirmed on Muscle biopsy
    • Previous trigger-free GA without issue

Discussion:

Management of Insulin Pump Perioperatively

  • Current guidelines recommend liaison with endocrinologist perioperatively
  • Endocrinologist letter:
    • Patient can adjust pump during the fasting period.
    • Preoperatively check BSL and Ketones. If BSL > 15mmol/L and/or ketones raised on arrival to hospital, postpone surgery and call the endocrinology registrar
    • Cease insulin pump pre-induction and commence IV insulin-dextrose infusion
    • Insulin infusion with IV dextrose to continue until she has tolerated one good meal and can self-manage pump.

Glucose monitoring

  • Continuous glucose monitor can be used to monitor BSL in conjunction with regular capillary measurements
    • IV fluid administration may affect accuracy as can alter the composition of interstitial fluid
    • Manual finger prick glucometer should be done regularly.
    • Perioperative target = 6-12mmol/L
    • Evidence to suggest monitoring system may be affected by diathermy/EMI. (Note effects are uncertain, likely a warranty issue).
    • Therefore, best practice to monitor capillary glucose regularly even for shorter procedures

Plan

  • Proceed to surgery
  • First on list, trigger-free anaesthesia
  • Management of insulin pump and continuous glucose monitor as per endocrine advice

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