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Perioperative beta-blocker therapy should be considered for all diabetic patients undergoing intermediate or major risk noncardiac surgery as a means to decrease the incidence of postoperative myocardial ischemia and infarction. It is prudent to also assess all patients for orthostatic hypotension. This is easily diagnosed by performing a "tilt test" in the operating room, with patients receiving appropriate intravascular volume resuscitation before initiating any form of regional or general anesthesia. Patients suspected of gastroparesis should receive a prokinetic drug before the administration of general anesthesia to decrease the incidence of gastric acid aspiration.

Aseptic technique is particularly critical for patients with DM to decrease the incidence of postoperative infection. In addition, temperature control is also essential, as hypothermia can lead to peripheral insulin resistance, hyperglycemia, deceased wound healing, and infection. Hypothermia has been associated with an increase in wound infection following colon resection, craniotomy for cerebral aneurysm clipping, and open heart surgery with cardiopulmonary bypass.

Intraoperative management of intravascular volume may require the use of a central venous pressure catheter, a pulmonary artery catheter, or transesophageal echocardiography (TEE) to optimally guide therapy and to prevent end-organ hypoperfusion. Arterial blood gas (ABG) analysis should include assessment of blood glucose levels, in addition to sodium, potassium, and pH. Patients with type 1 DM are predisposed to developing ketoacidosis during periods of major stress; therefore, they should be monitored by arterial blood gas analysis during and after major surgery.
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