MANAGEMENT OF HIGH-RISK PATIENTS IN THE P ERIOPERATIVE PERIOD - DIABETIC-PATIENTS

Preoperative care: The preoperative consultation is particularly impor tant in patients with diabetes mellitus due to the frequency and varie ty of degenerative complications. Cardiovascular disorders are the mai n cause of mortality, usually related to coronary artery disease, hype rtension, left ventricular dysfunction and impaired regulatory functio ns caused by damage to sympathetic and parasympathetic cardiac innerva tion. Diabetic dysautonomic neuropathy: Sudden cardiac arrest, rhythm disorders and unstable blood pressure during the operative period are well-known complications of diabetic dysautonomic neuropathy, increasi ng the risk of operative morbidity and mortality in diabetics. The dia gnosis is established with systolic blood pressure and heart rate, dia stolic blood pressure using the grip test respiratory arrhythmia, and the Valsalva manoeuvre. In addition, the cervical spine in diabetics i s stiffened by abnomal collagen structure, explaining the ten-fold inc rease in intubation difficulties. Gastroparesia, suggested by clinical signs, increases the risk of regurgitation and requires specific prev entive measures. Finally the neurology examination may reveal sensorom otor disorders which are particularly important because nervous lesion s may be exacerbated during the postoperative period. Choice of an ane sthesic: The major drawback of general anesthesia is that it masks sig ns of hypoglycemia. Spinal anesthesia is contraindicated in case of dy sautonomic neuropathy. Glucose control: Controlled insulin and glucose infusion in the perioperative period can avoid the risk of hyperosmol arity or ketoacidosis.