I'm Having Surgery in the Morning

Diabetes Technology Insulin Pumps
1

Just in time for the new year...I'm having surgery tomorrow morning. Officially it's called a Fifth Metatarsal Head Osteotomy.

I've been fighting with a pressure ulcer on the bottom my right foot, behind the little toe due to a deformity called a Tailor's bunion.

This all started when I noticed some pain in the area one day and then a blood blister popped. It promptly got infected, then the fun began.

It's got infected twice since then me being very, very, careful.

For the past seven months I been going to the wound care center at least once a week. We've tried a variety of treatments, plus three different pairs of diabetic shoes, custom orthotics, dozens of adjustments to the orthotics. Nothing seems to work. They wanted to put me in the Hyperbaric chamber, but because of some other Meds I take, that was not an option .

I've had two MRI's, and a Doppler study of veins and arteries of the legs, and find no other underlying problems.

At my last visit on Wednesday, my doctor asked me what I was doing on Monday :)

In most cases they simply shave off the offending protrusion of bone, but of course, that won't work for me. They are actually removing the entire end of the bone, about an inch. So in essence my little toe will be 'floating'.

So far the surgeon and my Endo are cool with me remaining on the pump during surgery (too bad if they weren't) I'll see how the anesthesiologist feels in the morning. It's supposed to be a local anesthetic and I going to request no sedatives be used. In any event I drafted up a 'cheat sheet' for my wife and the anesthesiologist on pump operation and plan on having a refresher with the wife this afternoon.

I'm running a little high today, (had to stop the Metformin yesterday, again, just in case. So, I'm having to cut down on Carbs even more than normal today.) running about 140. I'm going to wait another hour and then decide if it's the Carbs and Metformin, or the inevitable stress reaction (even if I'm really looking forward to getting this resolved) before I make any adjustments.

My Endo suggested reducing basal rate by 15% Monday morning, to let the BG float up a little, just to be safe. But left that decision to me.

Any advise on basal rates and surgery?

2

What is your BG control like normally during the surgery time of day? Does it trend up, down, or move sideways? Will you be fasting for surgery? Do you have any recent experience with fasting BGs during the surgery time of day?

Doctors like to use the term "permissive hyperglycemia," when talking about BG management during surgery. They simply want no chance of hypoglycemia during surgery. But they will happily trade that possibility for 200+ BGs. I, personally don't find this acceptable. I would want my body to have a maximum chance of a nominal infection-free post-surgery and recovery. Therefore my goal would be to have 80-120 mg/dl BGs during and after surgery.

Now I know this is not always possible, especially with special circumstances like surgery. But that's what I'd want to target. Why shoot for sub-optimal and end up with worse?

It's great that you have an ally in your wife. Let her hold all your insulin and D supplies (besides the pump itself) in case they admit you and try to strip these life-enabling tools from you! For me, as long as I have physical and cognitive capacity, I don't want any ignorant medicos involved in my BG control. We give them way too much credit, simply on the basis of their white lab coat. I consider all medical people a threat to my control unless they prove otherwise. Sorry for the rant!

I wish you the best of luck tomorrow!

3

Thanks.

For the most part I'm a flatliner...I've got my basal nailed.

Surgery is scheduled for 9AM and breakfast is about that time normally, so I don't expect any problems before then.

Last time I spent a few days in hospital, fasting, no Metformin then either, I was easily able to maintain BG in range with minimal tinkering. But I was conscious the whole time: Hopefully without complications tomorrow will be the same.

Yeah, fasting from Midnight tonight, which is normal for me anyway.

My normal target BG is 100-110, but I'll 'allow' it to range from 90-140 before intervention.

"I consider all medical people a threat to my control unless they prove otherwise." :-)
I feel exactly the same way, I'd even change it a little to say "a threat to my life"...and I have ample personal experience to back up that statement. I had a little 'incident' when I was in the hospital for a few days back in December of last year.
Due to their ignorance of diabetes and their complete, unfailing, reliance on Protocol, they almost killed me. I had a series of severe Hypos at their hands. I was sort of out of it with the other crap they had me on so it took a while for me to unquestionably refuse further 'treatment'.

Even after two separate severe Hypo events (a 30 and a 35) over an hour or so (and the administration of couple IV Dextrose pushes, the doctor refused to stop the IV insulin drip!

Thankfully the sedatives were wearing off about that time (wifey was a little confused at that time and trusted their judgement - she has since reevaluated her trust level when it comes to my diabetes) and I was able to convince the Charge Nurse, the Director of Nursing of what I wanted. I guess it helped a little when I had the Chief of Staff's cell phone number and could call him at home and wake him up at 3AM if needed. He's my personal physician.

I ended up with a total of five severe Hypos before I was able to enough Dextrose in me to counteract their murder attempt.

I fired one nurse and two attending physicians that visit. That really got some attention. The other doc almost gave me an antibiotic that was clearly contraindicated based on another medication I was taking.

So, now I have no concerns, whatsoever, with the hospital messing with my pump or other supplies. I was just in for two days for what turned out to be nothing more than an ocular migraine, but they still had to check everything. Well, the ER doc came in and said, "I see on your chart you are a patient of Dr. X, and that you manage your diabetes with an insulin pump. Let us know if you need anything in that respect." And the floor nurses seemed scared to even mention diabetes. :-)

Well, my pump is alarming now... I'm spiking... up to 188, it's got to be 'stress', (have not had lunch yet) even though I'm not really worried.

Off to bolus and set a temp basal....I'll be monitoring a little more proactively this afternoon and tomorrow.

4

Yikes! I would have thought hospital BG-mismanagement would be on the hyper side not hypo! Doctors are usually over the top hypo-phobic. Why were they giving you so much insulin? I guess the only thing I can learn from your experience is that doctors and nurses don't really know how to treat T1D. Even more dangerous, they think they do!

Your stable morning basal rates and BGs should hold for you tomorrow. Will you be able to finger-stick just before the procedure? I would keep a meter, strips, and glucose tabs near at hand up until the last minute, if possible.

5

I think that was their plan...It could be anything, the staff could have had a typo in data entry and without the background knowledge, the nurse could have simply blindly accepted to garbage out part of the solution

(I also had a dextrose IV in the other arm...Yep Dextrose in one arm w/ insulin in the other)

In their defense the system they use, called EndoTool, apparently has a 99.4% success rate of establishing glycemic control and then maintaining satisfactory BG's 97% of the time, based on clinical trials.
I'm probably just part of the 0.6%.

Yeah, my stuff is staying with me, and I'll check BG and make any final pump adjustments right before the procedure.

6

Fun afternoon

I've been running near 170 all day. Four corrections so far and on a 160% temp basal!

Interesting how non-stressful stress can impact blood glucose. Either that or the missing Metformin, or both.

Or it could be the hike the wife & I took through Ikea last night. That place is HUGE! Next time (if there ever is one) I'm taking a bicycle!

7

I've had two procedures under anesthesia since being T1, and a few other situations such as performances where I simply can't afford to go low. I don't run myself very high, but I shoot for about 150 and have had good success. I'm on a pump, so I can just set a temporary basal for the couple of hours pre- and post-op, then correct right after if needed. You shouldn't have any issues with post-op healing if you keep your BG's under 180 for just a few hours. It's not like you're running in the 200's for several days. Good luck with everything, I'm sure it will turn out OK!

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Thanks. It appears that going low is not going to be a problem. I’m sitting here at 170 after a handful of corrections and just the bumped the basal to 175%.

Really out of the ordinary for me.

9

Its conversations like these that keep me convinced that pumping isn't for me (at this point). 1 shot of lantus a day and my BG stays within a reasonable range. I've gone under the knife and told the doctor he doesn't need to worry about it because I'm not worried. Good luck, and also be reassured that the hospital will take good care of you. You are not the first person with diabetes they've taken care of--- unfortunately, a disproportionately high amount of the patients they take care of have diabetes.

10

Well you usually also take metformin, right? Clearly the understanding under which you take it is that it helps control your BG-- so if you had to discontinue its use recently, shouldn't the elevations be expected?

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Historically, if I'm not consuming any Carbs, the missing Metformin is completely unnoticed. I'm on very low Carbs (yes, not zero but close)today and my BG is still much higher than I expected.

Getting ready to bump the basal to 200%.

12

"1 shot of lantus a day and my BG stays within a reasonable range." Many of us are not so fortunate. I feel confident in saying that without the pump and CGM, I'd likely be dead.

I'm not worried at all, just trying to be prepared.

"also be reassured that the hospital will take good care of you" I unfortunately have personal, firsthand, experience that contradicts this claim.

13

Hi there! I had gallbladder surgery in July and last month I had major foot surgery that involved cutting my achilles and plantar fascia in my foot/leg. For both surgeries, I adamantly remained on my pump and on my Dexcom. In both cases I instructed them to ONLY treat my lows and nothing else....I would take care of the high when I was awake again. I showed the anesth. how to check my dexcom to see my BG reading and how to disconnect my pump in the event that I got too low. She was nervous about continuing with my basal insulin during surgery. My body is used to getting that small amount of basal all the time....I told her to deprive my body of that would likely really mess me up. Both surgeries went perfectly. I was a steady 88-120 all the way through on both. I've shared my experiences with both surgeries on youtube so thought I would share those:

Foot surgery: https://www.youtube.com/watch?v=Gbd0fLvQkwA&list=UUCwrDQ5Vj2JDPIu4Txjm_7w

Gallbladder Surgery: https://www.youtube.com/watch?v=gJO7KIq-1_U&list=UUCwrDQ5Vj2JDPIu4Txjm_7w

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Have faith… I also have personal firsthand experience that contradicts my own statement, but everything tuned out fine… a little faith goes a long way. I’ve been in car wrecks too but am not convinced I’m cheating death every time I get behind the wheel.

15

Thanks.

Well after another 2 hours on a 200% temp basal increase plus a couole more corrections and no change in BG I’m starting to think it’s something else entirely. Decided to change everything: New vial of insulin, new reservoir, new infusion set. Will check in an hour and see if it makes any difference.

16

the issue with a pump during surgery is what happens if it alarms. I always remove mine and give my blood sugar control to my anesthesiologist. I have never had an issue doing that. My thing is I woudl much rather the doctors control my blood sugar then having my pump alarm and they trying to use it during the procedure.

I have done it this way for everything from Cataracts to open heart and never ever had an issue. When I get finished in surgery I reattach the pump and off I go once again. I really think it is best to give control to the doctors during surgery. They have plenty to worry about during surgery and my pump beeping or using an Xray and exposing the pump to damage is just something I have never done. I have always had great success doing it this way........................rick

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Changed everything and BG dropped to normal in about an hour. Got about 3 hours sleep.

So it appears that it was not the metformin or ‘stress’

18

Ok, so surgery went fine. I elected not to have any sedation (Midazolam)or pain Meds (Fentanyl) during the procedure.

My surgeon and the anesthesiologist, told me I would change my mind after we got into the operating room. Nope.

I only got a local anesthetic and was fully conscious the whole time.

He ended up removing 4 cm of bone.

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So, what did the BG do? Glad to read you came through well. Gritty, I'll say.

20

I swear I replied to this last night, but it looks like it's gone now.

BG started floating up to 170 while in pre-op until I realized they had me on Lactated Ringers. Once I had them change that to Normal Saline, I dropped back down to 120ish. Stayed within 20 points for the remainder of my stay.

The anesthesiologist said something to the effect "That (ringers lactate) should make no difference at all." I replied with "Welcome to the world of Type 1 diabetes."

When I got home at 14:00, I was 114.

I was at 159 when I woke up this morning, easily remedied with a small correction. It appears the 'trauma' is having a little effect, but that is exactly what I anticipated.

Still not taking any pain meds, so I'm sure that is contributing a little.