An otherwise healthy, young, athletic Type I diabetic goes to the ER with abdominal pain. The patient has not eaten for two days, has a fever over 101 and the pain is in the RLQ. Having the most advanced (read expensive) medical system in the country where this occurred, the ER doctor orders blood work, X-ray, and ultrasound. The blood work shows elevated CRP, and a slightly elevated leukocytes, the X-ray shows nothing interesting, and the ultrasound shows a hard mass in the appendix. So, the surgeons are called and are more than happy to extract the troublesome vestigial organ.
Imagine you are an internist, considering the following what challenges might this patient face while going into surgery? What steps would you take before the patient goes to the OR?
Remember:
- The patient hasn't eaten for two days, and after the surgery it will be at least three.
- The patient's diabetes is under control with an insulin infuser (pump), and shows no secondary complications from the disease.
- Due to the infection, there is a marked increase in pro-inflammatory factors.
Why has the patient not eaten for two days? Too sick or too much abdominal pain? If he is still getting insulin, he could be in dangerous hypoglycemia (unless not much insulin is being administered by pump). If he has been in this pain for a while, possibly has peritonitis (has inflammation, fever, leukocytosis, and if pain has been present for awhile this suggests possible rupture from the "troublesome vestigial organ")? More information needed to rule this out.
ReplyDeleteAgreed. More information is needed but all of the signs point to appendicitis, possibly ruptured which could lead to peritonitis depending on how long it's been ruptured, surgical technique, etc. I think his biggest problem in regards to surgery will be with T1DM. Diabetic patients are typically at a 50% higher risk of complications during surgery than non-diabetics. Glycemic control during surgery is a fine balance to prevent shock, cerebral clots, or any kind of vascular event. Most diabetic patients (being T2DM) have preexisting cardiac abnormalities and neuropathies, the fact that this guy is young is a good point on his side.
ReplyDeleteTV doctor-show breaks from reality aside, assuming this guy did actually get an appendectomy, I agree with JJ that having an unfed diabetic patient under the knife is extremely dangerous. I wonder - would it be possible or potentially harmful to place a glucose-IV in the patient before he goes in? Controlling blood sugar in type I diabetics is crucial to preventing other complications from the disease. Without well-regulated blood sugars, this patient is at risk for seizures and syncopies before, during, and after surgery (assuming he can even wake up from the anesthetic from such a low blood sugar) and allow the parts of his immune system not attacking the insulin in his body enough energy to fight off any post-op infections.
ReplyDeleteOne final point - I'm not sure that you can draw conclusions about T1DMs from T2DMs because the factors influencing T2DM are less immunologically-related and more a result of lifestyle (in most cases. There are, of course, lots of skinny people classified as type2). From what I've read on T1DM, there are many potential complications in most systems of the body that come about as the disease progresses and the patient ages, but I don't believe that they have an increased chance of "pre-existing" or congenital abnormalities of the heart. Mostly they're too sweet, right?
Alison, good call :-) You got it right, but type 1s bodies are not immune against insulin. They are autoimmune against their own pancreatic B-cells.
ReplyDeleteJohnC495: The patient was unable to eat from abdominal pain. Nothing weird, and the ultrasound showed that the appendix was still intact. Although aggressive antibiotic treatments are certainly a good idea for a diabetic (increased risk of post-op infection) during any surgery.
I'm a bit out from my days as a hospitalist pediatrician... but if we did have a patient with Type I DM, it was always important for us to normalized the blood sugars prior to surgery and keep them normal post-operatively as well. This came up fairly often, both for planned surgeries in addition to circumstances like the one described above.
ReplyDeleteAllison, you are right, the "easiest" way to keep the tightest glucose control is to have simultaneous infusion of both short-acting insulin (either through an IV or through a subcutaneous pump) and continuous infusion of glucose containing IV fluids. These are kept at a maintenance rate and adjusted as needed based on regular checking of blood glucoses (usually every hour). If the patient did require more fluid resuscitation for surgical purposes, this would be done with isotonic fluids in addition to what was already being infused.