WBR0221

Author	[[PageAuthor::Mugilan Poongkunran M.B.B.S [1]]]
Exam Type	ExamType::USMLE Step 3
Main Category	MainCategory::Inpatient Facilities
Sub Category	SubCategory::Endocrine, SubCategory::Endocrine
Prompt	[[Prompt::A 29 year old female is admitted to the hospital for an elective cesarean section. She is on her 38th week of pregnancy. The patient was diagnosed with type 1 diabetes three years ago. She is currently on NPH (32 units before breakfast, 26 units at bed time) and regular insulin ( 22 units before breakfast, 22 units before supper). Before admission her glucose control was acceptable and she denied hypoglycemic symptoms. She does not have any chronic diabetic complications. The procedure is scheduled on the next day of admission. Which statement correctly describes the proper preoperative management of diabetes in this patient?]]
Answer A	[[AnswerA::Half dose of NPH and regular insulin on the night before surgery, no insulin on the day of surgery and insulin according to the sliding scale to keep the blood glucose below 250mg/dl.]]
Answer A Explanation	AnswerAExp::'''Incorrect''' : Stopping insulin on the day of surgery is not advisable because of increased chance of stress induced hyperglycemia and ketoacidosis.
Answer B	AnswerB::No insulin on the night prior to surgery or on the morning of the surgery and sliding scale to keep the blood glucose below 200 mg/dl.
Answer B Explanation	AnswerBExp::'''Incorrect''' : Stopping insulin on the day of surgery or the night before surgery is not advisable because of the risk of ketoacidosis in type I diabetic patients.
Answer C	AnswerC::Normal insulin dose on the night before surgery, half dose on NPH and regular insulin on the morning of surgery, followed by sliding scale insulin to maintain blood glucose below 200 mg/dl.
Answer C Explanation	AnswerCExp::'''Incorrect''' : This option gives suboptimal control. This can be used if facilities for starting insulin drip are not available.
Answer D	AnswerD::Normal insulin dose on the night before surgery, and start the patient on an insulin drip and infusion of D5 1/2NS with 40 mEq of KCL to keep the blood glucose below 160 mg/dl.
Answer D Explanation	[[AnswerDExp::Correct : Normal insulin dose on the night before surgery, and start the patient on an insulin drip and infusion of D5 1/2NS with 40 mEq of KCL to keep the blood glucose below 160 mg/dl would be the best option for controlling the patient diabetic status]]
Answer E	AnswerE::No change in insulin dose.
Answer E Explanation	AnswerEExp::'''Incorrect''' : Changing to insulin drip and infusion is best way to prevent perioperative diabetic complications.
Right Answer	RightAnswer::D
Explanation	[[Explanation::During pregnancy, the requirement of insulin increases because of the diabetogenic effects of the placental hormones, especially in the second trimester. Following a normal labor or caesarean section, there is decrease in level of these hormones, which drastically decreases the patient’s insulin requirement. This patient has type I diabetes and hence should be kept on insulin to prevent ketoacidosis, even if she is not eating. The patient should take her normal dose on the night before surgery. Since the patient will not be eating after midnight, the procedure should be scheduled during the early morning hours. Insulin infusion is the best way to treat a patient perioperatively and the drip rate adjusted to keep her glucose level below 160 mg/dl. There are no set guidelines for the target glucose levels, however tight control prevents complications periopertively. Intravenous insulin has a half-life of 5 min and their hypoglycemic effects will not last more than 30 minutes. The amount of insulin infused during last 24 hr give us a rough calculation of the recent insulin requirements. Patients should be switched to scheduled insulin dosage as soon as they start tolerating food. Educational Objective: References: ]]
Approved	Approved::Yes
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