October 28, 2008

Safe Surgery with Diabetes

If your doctor is honest he or she will have told you that people with diabetes have a very high risk of developing a serious infection or other complication after surgery. But having diabetes also makes it likely that a person will need surgery. So with that in mind let's look at what you can do if you are a person with diabetes to make sure that you emerge safely from any surgery you might have to undergo.

1. People with Diabetes and Normal Blood Sugar Fare as Well as Normal People. I can't point you to a study that proves this, because, sadly, there are no studies that involve people diagnosed with diabetes who maintain normal blood sugars. The only data we have is anecdotal--i.e. reports of people who have normalized their blood sugar despite a diabetes diagnosis. And the news from them is very good.

This makes sense. There are two reasons that people with diabetes have such poor outcomes in a surgical setting. One is because uncontrolled high blood pressure destroy the tiny capillaries that should bring immune cells to healing tissues, which allow bacteria to grow unopposed.

The other thing high blood sugars do is destroy nerves. Early in the process these high blood sugars kill the smaller nerve, then then later on, the larger nerves. This has a huge impact on the body's ability to fight infection because we now know thanks to Kevin Tracy's ground breaking research about the immune system published in Nature in 2002 that the nerves play a major role in sensing and then triggering the immune response to invasion. So when the nerves are damaged by high blood sugars, the immune system may not learn that an infection is taking place. This may be a major reason why neuropathy leads to the uncontrollable infections that lead to amputation.

But if you keep your blood sugars within normal limits--under 140 mg/dl (7.7 mmol/L) at all times or as close to that as you can manage--your capillaries and nerves should remain functional, and if that is the case, there is not reason why you should have any more exposure to infection than a normal person.

Family doctors don't know this, but I was very heartened when I had surgery last spring that my young surgeon did. In fact, when I asked if I might need to raise my carbohydrate intake to promote healing (a concept that I recalled reading in the book Protein Power years ago) the surgeon told me that a low carb diet was better, not worse, for healing, especially in people with diabetes.

I followed her advice and followed a stringent very low carb diet--no more than 10 grams per meal--for eight weeks--two weeks before the surgery and then six weeks after--and healed so quickly that the surgeon told me that she wished the rest of her patients would do whatever it was that I'd done.

2. MRSA is a Huge, New Threat to All People who Have Surgery. MRSA is a "superbug" form of staphylococcus bacteria which is resistant to most antibiotics. It has spread through hospitals at an alarming rate and is causing an epidemic of terrible wound-related complications. Hospitals have been very slow to respond effectively to it. There has been no requirement that hospitals report when they have MRSA infections and the steps needed to eliminate MRSA from a hospital once it has been contaminated are time consuming and expensive. As a result, many hospitals have not taken the steps they should take to prevent this infection from spreading and as a result MRSA has become a huge threat to all hospitalized patients.

Most people don't realize this, but it turns out that hospitals do not get the visits from the health departments that restaurants get. No outsider tests hospital surfaces for bacteria the way they test the counters in all restaurant kitchens. Hospitals are left to police themselves--a strategy we have seen in all sectors of society usually means that no policing occurs.

Because of this, if you are going into a hospital for surgery you should take steps to protect yourself.

The first thing you should do is read 15 Steps to Reduce Your Risk of Hospital borne Infection

My surgeon counseled me to wash with antibacterial soap for three days before surgery, which I did. I followed this up after surgery by washing my hands with antibacterial soap before doing any wound care. I had no problems and I suspect that this rigorous attention to decontamination helped.

If you are in the hospital for any period of time, the most important thing that your loved ones can do is to insist that anyone who attends you washes their hands before caring for you. This simple step has been shown in studies to prevent transmission of MRSA. Unfortunately, studies have also shown that most doctors and many nurses continue to neglect this step.

MRSA is taking a terrible toll. It killed the woman who was my roommate in the hospital last December. It looks like it may be destroying Tom Brady's knee. I am seeing more and more reports of terrible, nonhealing wounds in surgery support discussion groups, and from the treatments being used--repeated surgeries being used to open wounds and debride them, it looks like many people are being treated for MRSA without being informed by their surgeons that this is what is going on.

If you do develop MRSA it is very important to understand that you are infectious to others. Anyone with MRSA should be kept away from children who can pick up the bacteria and take them to schools or day care centers where they can enter broken skin and cause fatal infections. You must also insist that everyone who tends you follow rigorous decontamination techniques--like removing the shoes they wear in the sickroom--which you can learn more about on the hospitalinfection.org web site.

3. A Healing Diet is a Diet Rich in Greens and Colorful Vegetables. It is not enough to eat a low carb diet. To heal yourself, you will want that low carb diet to include a lot of fresh dark green vegetables as well as small portions of colorful peppers and tomatoes. Yes, these latter items have a bit of carbohydrate, but the value of the micronutrients they contain is well worth the very slight raise in blood sugar they may cause.

Vitamin K which is found in greens is extremely helpful to the healing process. You will also want to eat natural food sources of Vitamin C which have been shown over and over again in research to be far more effective than the vitamin taken in isolation in pill form. There are other micronutrients in fresh vegetables that are not found in pills. In addition, Vitamin C now all comes from China and is subject to the dangerous contamination that affects all Chinese products.

The juice of half a lemon or lime a day added to your surgery diet will give you all the vitamin C you need and be very helpful towards healing. Squeezing the juice of fresh lemons or limes into seltzer or tea is an easy way to get this valuable nutrient.

4. Start Your Surgery Diet Before Surgery. If you have advanced warning that you will be having surgery, start your surgery diet as soon as possible. Normalizing your blood sugar before surgery rather than just afterwards is very important, and building up body stores of micronutrients from fresh vegetables and greens is important, too.

5. Before the Day of Surgery Talk to your Surgeon about Keeping Blood Sugars Normal During the Surgery. Unfortunately, it is still common practice for anesthesiologists to start glucose drips before surgery. If you wait until the day of surgery (as I did) to ask that you not be hooked up to a glucose drip, you may find that the anesthesiologist does it anyway. So this is something you should discuss with your surgeon beforehand so that they can inform the anesthesiologist what protocol to follow. I was told that insulin is usually not administered during surgery, so if you are given a glucose drip and do not have the ability to lower your own blood sugars, you may end up with a very high blood sugar during surgery which will shut down your immune system and make it harder to heal.


UPDATE November 16, 2008: An article published in the Bellingham Herald written by investagative journalists from the Seattle Times describes in great detail how hospitals in one city ignore and downplay the MRSA epidemic, how doctors hide deaths by MRSA, and how dangerous this germ really is. Read this whole article before you check in for surgery. It might save your life or limbs. (The whole series also appears in the Seattle Times but this version is easier to read online.)

Unfortunately, this article is no longer available online.


Unknown said...

I had oral surgery last year. I didn't count anything, but I was careful about carbs, fbg was running in the 80s before the surgery. I did talk to the surgeon about the iv before hand and made sure it didn't have any glucose in it. He did say I was healing better than he expected. I was not able to eat anything solid for a long time so I pretty much lived on Walker Diet protein shakes, eggs, meatloaf, chicken salad, chili and homemade pureed chicken-vegetable soup.

My uncle got the MRSA and died. He was in a VA nursing home and got pneumonia, I don't know if he got the MRSA in the VA or in the county hospital he was transferred to.

Harold said...

Accredited hospitals go through a rigorous evaluation procedure that covers everything including hospital acquired infections. Stay out of non accredited hospitals unless you evaluate why they are non accredited. Sometimes that can be because they take the most difficult patients (medical school university hospitals) and fail because their death rate is higher as would be expected.

Jenny said...

Sadly, the accreditation process does not guarantee a hospital is safe from MRSA.

The hospital where my roomate acquired MRSA was accredited.

The accreditation process does not involve ongoing frequent testing and many hospitals do not keep accurate data about infections.

The recent change in Medicare which states that Medicare will no longer pay for treatment of hospital acquired infection may help get hospitals to take this issue more seriously as it will start costing them money. Until now, it only cost them money to prevent infection and they earned extra money treating infection's victims.

I heard this discussed on NPR in an interview with the lady who started http://hospitalinfection.org.

Anonymous said...

Mother was very unwilling to go into hospital recently (for a non-surgical illness) as the last two times they cured what she went in with and gave her cellulitis (MRSA was never actually mentioned but it was pretty antibiotic resistant in both cases)Probably fortunately they sent her home with a loaner nebuliser and told her to act as if she was still in hospital. When the nurse made her daily visits I was tempted to hose her down before letting her in the house.

Sadly hospital borne infections seem to have become more rife as the size of the hospitals has increased. Gosh, do you think putting hordes of ill people all together in the same gigantic building is the best way to deal with them?

I never want to go in the nearest hospital ever again, the food alone would probably kill me. High carb high fat zero nutrition.