Principle of surgery
People with insulin-dependent diabetes must strike a balance among caloric intake, exercise, and insulin dose. Any decrease in regular caloric intake or increase in activity, metabolic rate, or insulin dose can lead to hypoglycemia and vice versa.
Patients with non-insulin-dependent diabetes usually produce insulin, but in insufficient amounts because of decreased insulin activity, insulin receptor resistance, or both. This form of diabetes typically begins in adulthood,is exacerbated by obesity, and does not ,usually require insulin therapy. It is treated by weight control, dietary restrictions, and the use of oral hypoglycemia. Insulin is required only if the patient is unable to maintain acceptable serum glucose levels using the usual therapeutic
measures. Severe hyperglycemia in non-insulindependent diabetic patients rarely produces ketoacidosis bur leads to a hyperosmolar state with altered levels of consciousness.
Short-term, mild-to-moderate hyperglycemia is usually not a significant problem for people with diabetes. Therefore when an oral surgical procedure is planned it is best to err on the side, of hyperglycemia rather than hypoglycemia that is, it is best to avoid an excessive insulin
dose and to give a glucose source. Ambulatory oral surgery procedures should be performed early in the day, using an anxiety reduction program. If IV sedation is ·not being used, the patient should be asked to eat a normal meal and take the usual morning amount of regular insulin and a half dose of neutral protamine hagedorn (NPH) insulin (Table 1-1). The patient’s vital signs should be monitored; if signs of hypoglycemia, such as hypotension, hunger, drowsiness, nausea, diaphoresis, tachycardia, or a mood change occur,. an oral or IV supply of glucose should be administered. Ideally offices have an electronic glucorneter available with which the clinician or patient can readily determine serum glucose with a drop of the patient’s
blood. This device avoids the need to steer the patient toward mild hyperglycemia. If the patient will temporarily be unable ‘to eat after urgery, any delayed-action insulin (most commonly NPH) normally taken in the morning should be eliminated and ‘restarted only after normal caloric intake resumes. The patient should be advised to monitor serum glucose closely for the first 2-1 hours postoperatively and adjust insulin accordingly.
If a patient must miss a meal, before a surgical procedure, the patient should be told to skip any morning insulin and only resume insulin once they are able to receive a supply of calories. Regular insulin should then
be used, with the dose based on serum glucose monitoring and as directed by the patient’s physician. Once the patient has resumed normal dietary ha~s and physical activity, the usual insulin regimen can be restarted.
People with well-controlled diabetes are no more susceptible to infections than people without diabetes, but – they have more difficulty containing infections. This is caused by altered leukocyte function or by other factors –
that affect the body’s ability to control an infection. Difficulty in containing infections is more significant in people with poorly controlled diabetes. Therefore elective oral surgery should be deferred in patients with poorly
controlled diabetes until control is accomplished. However an emergency situation OLa serious oral infection