1)     RECOMMENDATIONS

a)      General Approach

i)        Patient should be given ½ of the usual morning insulin dose, at the normal time at home, prior to admission

ii)       Maximize speed of recovery and early return to oral food intake

b)      Pre-anesthetic Medications

i)        Butorphanol, buprenorphine, or oxymorphone combined with midazolam or acepromazine at the lower end of the dose range

(1)   Less nausea than hydromorphone or morphine

c)      Induction

i)        Propofol

(1)   Propofol has some ability to stimulate appetite temporarily after its use

ii)       Etomidate

(1)   If significant cardiac concerns

(2)   Can cause some retching at induction and recovery

(a)    Effective premeds usually prevents this effect

(b)   Precede etomidate with IV diazepam

d)      Maintenance

i)        Isoflurane or Sevoflurane

e)      Support

i)         Fluid support is highly recommended

2)     PRECAUTIONS

a)      Pre-anesthetic Medications

i)        Avoid heavy sedation with non-reversible agents

(1)   Acepromazine

(a)    Reserve for patients in good to excellent categories

(b)   Is used, dose conservatively

ii)       Hydromorphone

(1)   Can cause transient nausea

iii)     Morphine sulfate

(1)   Can cause transient nausea

b)      Induction

i)        Etomidate may stimulate retching

(1)   Effective premeds usually prevents this effect

c)      Maintenance

i)         Nothing specific

d)      Support

i)        Serial blood glucose testing can help identify hypoglycemic trends

(1)   Dextrose IV can be used as indicated to stabilize hypoglycemia