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Anaesthetic management of the patient with diabetes
control of blood glucose has been shown to decrease microvascular complications, but not to reduce macrovascular complications, diabetes-related mortality or overall mortality.
Types of diabetes
Type 1 diabetes (T1DM; previously known as insulin-dependent or childhood-onset diabetes) results from a failure of insulin secretion (Table 1). This is caused by an immune-mediated destruction of more than 90% of insulin-secreting islet cells. Diabetes-associated autoantibodies may be present at the time of diagnosis, but may be undetectable years after onset. Type 1 diabetes affects genetically predisposed individuals with altered human lymphocyte antigen (HLA) on the short arm of chromosome 6 (HLA-DR3, HLA-DR4 and HLA-DR3/DR4 phenotypes). The complete absence of insulin in type 1 diabetes leads to lipolysis, proteolysis and ketogenesis. The treatment is insulin substitution. Type 2 diabetes (T2DM; previously known as non-insulindependent or adult-onset diabetes) is caused by insulin resistance usually associated with defective insulin secretion (Table 1). It can often be treated by a combination of diet and oral hypoglycaemic drugs, although some might require exogenous insulin. Of those patients with type 2 diabetes, 80% are obese. Impaired glucose tolerance (IGT) and impaired fasting glucose (IFG) are intermediate conditions in the transition between normality and diabetes (Table 1). Patients with IGT or IFG are at high risk of progressing to type 2 diabetes. In the UK, 17% of individuals aged 40–65 are affected. Gestational diabetes constitutes any glucose abnormality that develops during pregnancy and disappears after delivery. It affects 4% of pregnant women. Long-term follow-up studies show that the risk of progressing to diabetes after pregnancy is about 70%. Other forms of diabetes include diabetes secondary to other pathological conditions, for example pancreatitis, trauma or surgery to the pancreas, drug or chemically induced diabetes or
diabetes mellitus is the most common endocrine disorder. Type 1 diabetes is caused by an immune-mediated destruction of insulin-secreting islet cells. Type 2 is due to insulin resistance. The prevalence is expected to double by 2030 in the UK. Patients with both types of diabetes demand control of their metabolic status, normoglycaemia, the avoidance of ketoacidosis and electrolyte disturbances. The consequences of long-term diabetes – cardiovascular diseases, autonomic and peripheral neuropathy, stiff joint syndrome and renal insufficiency as well as the associations of type 2 diabetes of obesity and lack of exercise – demand understanding and skill from the anaesthetist. A good preoperative evaluation of long-term effects such as coronary heart disease, hypertension and renal insufficiency plus the risk of difficult intubation and pulmonary aspiration are of major importance. The aim is perioperative homeostasis of electrolytes and blood glucose as well as the maintenance of normovolaemia and maximal reduction of perioperative stress. Sufficient postoperative pain relief and prevention of nausea and vomiting ensure early enteral feeding. The avoidance of infection with calculated antibiotic therapy, early mobilization and physiotherapy are essential. Minor surgery can often be performed as a day case. This demands adequate care at home and motivation and compliance of the patient. day case centres should implement guidelines for the treatment of patients with diabetes, and strictly comply with them. There is no evidence that anaesthetic technique influences morbidity or mortality in patients with diabetes.
Keywords anaesthesia; day surgery; diabetes mellitus; glucose–insulin–
potassium regime; obesity; oral hypoglycaemics
There are an estimated 2.35 million people with diabetes in England. This is predicted to reach more than 2.5 million by 2010, of which 9% of cases will be due to an increase in obesity. The prevalence in the UK is expected to double by 2030. Currently, 10% of hospital in-patient spending is used for the care of people with diabetes.1 Weight gain and abdominal or visceral fat, independent of body mass index, are associated with an increased risk of diabetes. Diabetes shortens life expectancy by 10 years in type 2 and 20 years in type 1. The causes of death in 80% of these patients are cardiovascular events. Long-term intensive
Fasting blood glucose (mmol/litre) diabetes impaired glucose tolerance impaired fasting glucose ≥ 7.0 < 7.0 ≥ 6.1 but < 7.0 2-hour blood glucose (mmol/litre) following standard glucose challenge ≥ 11.1 ≥ 7.8 but < 11.1 < 7.8
Peter Klepsch is Locum Consultant Anaesthetist at Frenchay Hospital, Bristol, UK. He qualified from Free University Medical School Berlin, Germany. He trained in anaesthetics in Berlin. His special interest is day case anaesthesia, total intravenous anaesthesia and regional anaesthesia.
one positive blood test is required in a symptomatic patient, whereas two positive blood tests are necessary in an asymptomatic patient
AnAESTHESiA And inTEnSiVE cArE MEdicinE 9:10
© 2008 Elsevier ltd. All rights reserved.
delays digestion and absorption of starch and sucrose • glucobay Meglitinides Stimulates insulin secretion by binding to ATP-dependent K+ channels in pancreatic β-cells • nateglinide: Starlix • repaglinide: novonorm Table 2 Acute medical presentations • Hypoglycaemia: tachycardia. altered regulation of breathing. glucophage Sr (usually first line) Treatment The treatment of diabetes includes diet. For the different groups of oral hypoglycaemic drugs see Table 2. All rights reserved. tremor. diamicron. Microvascular complications predominate in patient with T1DM. Semi-daonil. glucophage. β-blocker administration or alcohol intake. especially in combination with shortacting insulin before meals. cardiac dysrhythmias and sudden death. Minodiab • gliquidone: glurenorm • Tolbutamide: Tolbutamide Thiazolidinediones increased peripheral glucose uptake and decreased gluconeogenesis • Pioglitazone: Actos • rosiglitazone: Avandia. In addition to the above cardiovascular symptoms. Euglucon Shorter-acting • gliclazide: gliclazide. • Diabetic ketoacidosis: uncontrolled catabolism associated with insulin deficiency. whereas macrovascular complications are more common in patients with T2DM. orthostatic hypotension. Other Patients with diabetes show an increased risk of wound infection and delayed wound healing. The ‘prayer sign’. glibenese. confusion and coma. a long-acting insulin. commonly present in elderly patients with type 2 diabetes. impotence and gastroparesis. resting tachycardia. Stiff joint syndrome An estimated 30–40% of patients with T1DM show signs of limited joint mobility. sweating. Oral hypoglycaemics Biguanides decrease hepatic glucose output and increase insulin action • Metformin: Metformin. In acute hyperglycaemia or badly controlled diabetes. asymptomatic hypoglycaemia. correlates with the presence of the stiff joint syndrome. is becoming popular. lower AnAESTHESiA And inTEnSiVE cArE MEdicinE 9:10 © 2008 Elsevier ltd. Sulphonylureas increased release of endogenous insulin and enhanced insulin receptor function by binding to ATP-dependent K+ channels in pancreatic β-cells Long-acting • chlorpropamide: chlorpropamide • glibenclamide: glibenclamide. . Renal failure This reflects a lesion in the microvasculature of the renal glomerulus and occurs eventually in one-third of patients with T1DM. may be associated with fasting. This can involve the atlanto-occipital joint and may lead to difficulties in laryngoscopy and tracheal intubation. recombinant technology from Escherichia coli or human analogue insulin. an inability to approximate the palmar surface of the interphalangeal joints. Type 2 diabetes First-line treatment is the alteration of lifestyle and diet. The insulin is given either as single subcutaneous injections or by using a continuous subcutaneous injection via a pump. oral hypoglycaemic drugs and insulin. daonil. rapid-onset soluble insulin • soluble insulin mixed with protamine or zinc salts to produce a longer action but keeping the rapid onset • long-acting insulin. Type 1 diabetes Insulin substitution is the treatment for T1DM. This is produced from beef or pork pancreas.Endocrinology diabetes related to specific single genetic mutations that may lead to rare forms of diabetes. gastric emptying can be significantly delayed (Figure 1). If that fails. Treatment regimes include a combination of three different groups of insulin: • short-acting. higher ventilation pressures. Autonomic neuropathy can lead to silent ischaemia. 442 Microalbuminuria is an early sign of diabetic nephropathy. Avandament (combination with metformin) Acarbose inhibits intestinal α-glycosidase. autonomic neuropathy can lead to bladder atony. Systemic associations in patients with diabetes Systemic complications become more common with increasing duration of the disease. the use of oral hypoglycaemic drugs or insulin treatment becomes necessary. • Hyperosmolar non-ketotic coma: hyperglycaemia without ketosis. insulin glargine. diamicron Mr • glimepiride: Amaryl • glipizide: glipizide. Cardiovascular Diabetes is considered as a coronary artery disease equivalent and might support perioperative β-blockade and statin therapy. The primary prevention of T2DM is avoidance and treatment of obesity. Renal impairment alters drug clearance and is a positive predictor for the presence of cardiovascular disease. The obese or morbidly obese patient has additional risks of a potential difficult airway. These are mainly effects of macroangiopathy and microangiopathy (Table 3).
Red circles.05) compared with untreated patients with diabetes. To avoid duplication of effort. normal electrolyte homeostasis and avoiding ketoacidosis and dehydration. anaesthetic drugs and immobilization. ECG should be considered in all patients even if they are below the age when a Gastric emptying 100 Radionuclide remaining in stomach (%) 90 80 * * 70 * * 60 * 50 * * 40 * * Minor surgery Minor surgery is defined as a patient missing only one meal and being able to eat or drink within 4 hours of surgery. cerebrovascular disease. if given. Am J Med Sci 1985. all patients with diabetes should have an annual review. Aggressive treatment of preoperative hyperglycaemia may help to reduce the incidence of intraand postoperative elevation of blood glucose. Diabetic gastroparesis: an abnormality of gastric emptying. and green circles. hypertension • Microangiopathy: nephropathy. . but these data have not yet been extrapolated to include the general surgical population. oxygen reserve and a higher risk of developing atelectasis. cerebrovascular disease and peripheral vascular disease. hepatic glycolysis and gluconeogenesis. In the UK. This reduces the depression of insulin levels. Alone or in combination with smoking. Patients with T2DM omit their oral hypoglycaemic medication on the day of surgery except metformin. hourly perioperatively and 2 hourly postoperatively until the patient is eating and drinking. Postoperative management The postoperative aims are sufficient pain relief to avoid stress (with its resulting hormonal and metabolic response) and the avoidance of postoperative nausea and vomiting to re-establish the earliest possible oral dietary intake. retinopathy and disorders of the nervous system such as autonomic neuropathy and peripheral neuropathy • Other: stiff joint syndrome.000 patient-years there was no episode of lactacidosis. if appropriate for the surgery. HbA1c and urine analysis for albumin and ketones can also give useful information about glucose control. in control subjects. Intraoperative management The following factors influence perioperative blood glucose levels: diabetes itself. 443 30 0 20 40 60 80 100 120 Time (minutes) Gastric emptying of the solid test meal (99mTc sulphur colloid-labelled chicken liver/beef stew). hormonal and metabolic response to surgery. Blood glucose should be measured 1 hour preoperatively. it may be possible to obtain this review from the patient’s GP. in patients with diabetes after metoclopramide (10 mg intravenous bolus). 289: 240-2. starvation (pre.Endocrinology Long-term complications of diabetes mellitus • Macroangiopathy: coronary artery disease.4–6. blue circles. glucagon and cortisol levels is of major importance. Special attention should be given to silent ischaemia. In 176 studies representing 35. Reducing the perioperative catabolic and sympathetic response characterized by elevations in circulating catecholamines. Standard deviations are shown. blood pressure and cholesterol. this causes a higher incidence of chest infections. It will mostly be undertaken in a primary care setting and should include assessment of microvascular and macrovascular status. should be continued for at least 2 hours after the first oral intake. Preoperative urea and electrolyte levels and blood glucose should be checked. Insulin. The widely accepted aim is a blood glucose level < 10 mmol/ litre. in patients with diabetes. increased risk of postoperative wound infection and delayed wound healing Table 3 routine ECG is done.and postoperative). decreased lung diffusion capacity and lung volumes. All rights reserved. renal failure. orthostatic dysregulation and the potential for difficult intubation. The goal for the management of anaesthesia in patients with diabetes is maintaining normoglycaemia. wound healing disorders. A Cochrane review does not support the 48-hour abstinence of metformin before anaesthesia because a related lactacidosis is unlikely. growth hormone. dehydration and electrolyte loss.1 mmol/litre) glucose control has been shown to improve outcome in patients in intensive care units mainly after cardiac surgery. Management of anaesthesia Preoperative evaluation of patients should focus on the possible complications of diabetes. Reproduced with permission from Wright RA. The patients should be first on the list and take their oral hypoglycaemic drugs as soon they are able to have the first meal. anastomotic insufficiency. Clemente R. plus a full blood count/clotting screen. *Statistically significant differences (P < 0. infection. Tight (4. Blood glucose levels of 12–14 mmol/litre are associated with major complications such as exacerbation of ischaemic damage to the brain and myocardium.3 Figure 1 AnAESTHESiA And inTEnSiVE cArE MEdicinE 9:10 © 2008 Elsevier ltd. This is achieved by an infusion of glucose–insulin–potassium (GIK) solutions. Chest radiograph and echocardiogram might be indicated if the routine tests and the clinical history indicate it. HbA1c. Wathen R. which should be omitted from the night before.
Minimally invasive surgery and epidural anaesthesia have been suggested to reduce perioperative insulin resistance and hyperglycaemia in abdominal surgery. Intermediate surgery. Postoperative pain control and stress reduction are paramount. a sliding scale with separate insulin and glucose–potassium infusions can be used. gastric volumes are minimal. insulin and potassium (GIK) regime should be started. Patients for minor surgery on the afternoon list take their normal oral hypoglycaemics or half of their usual morning dose of insulin with a light breakfast 6 hours before surgery. especially if a difficult airway is likely. Minor surgery can be carried out both first on the morning or first on the afternoon list but intermediate surgery first on the morning list only. Metoclopramide prophylaxis to reduce gastric volumes seems to be unnecessary unless the patient has a prolonged history of poor blood glucose control. . The choice of the anaesthetic drug has no influence on the outcome. except that the blood glucose should be between 5 and 13 mmol/litre. with postoperative fasting between 1 and 4 hours. The morning dose of both oral hypoglycaemics and insulin should be omitted. If the patient takes insulin only twice a day. Consider reducing long-acting insulin taken the night before surgery by one-third. Following the guidelines for the assessment and management of patients with diabetes undergoing day surgery. the patient omits the morning dose of insulin or oral hypoglycaemic and takes it with the delayed breakfast after being operated first on the list. Regional anaesthesia should be considered in every patient with diabetes. If the blood glucose is above 13 mmol/litre check for intercurrent infection or the patient not being fasted and consider postponing the surgery. All rights reserved. Diabetes per se does not predict adverse outcome following minor ambulatory surgery. Some authors5 suggest a possible exacerbation of a peripheral neuropathy after regional anaesthesia. Alternatively. Discharge criteria are the same as for patients without 444 diabetes. A recent study4 concluded: ‘In elective surgical patients who have fasted before surgery. reflecting their blood glucose levels on admission.3 postulated a delayed gastric emptying in diabetic patients (Figure 1). Oral hypoglycaemics and insulin should be omitted on the day of surgery and a glucose–insulin regime should be started at least 2 hours prior to surgery. If blood glucose exceeds 10 mmol/litre a glucose. should be carried out first on the morning list. A recent retrospective study6 in patients with diabetes with AnAESTHESiA And inTEnSiVE cArE MEdicinE 9:10 © 2008 Elsevier ltd. There is no special limitation for ambulatory surgery in patients with diabetes. even in diabetics with severe neuropathic symptoms. Postoperative GIK infusion should be maintained until 2 hours after the first meal. After surgery. ○ ○ ○ All usual selection criteria for day surgery met intermediate surgery can be scheduled for a morning list Patient has no history of: ○ repeated hypoglycaemic attacks ○ recurrent admission to hospital with complications related to diabetes Patient and carer are able to measure blood glucose at home Patient and carer understand about hypoglycaemia and its treatment HbA1c < 8% reproduced with permission from the British Association of day Surgery Table 4 Day cases Despite an increased risk of complications in major surgery. Criteria for selection of patients with diabetes in day surgery2 ○ ○ ○ Major surgery Patients should be admitted the day before surgery to allow sufficient time to correct glucose and electrolyte abnormalities.2 minor and intermediate operations can be carried out if the criteria are fulfilled (Table 4). give one-quarter of the daily dose of rapid-acting insulin. they have their delayed lunch with their usual lunchtime medication. Regional anaesthesia shortens the time of postoperative fasting and local anaesthesia eliminates perioperative fasting at all. If the patient’s blood glucose level on admission is less then 5 mmol/litre and the patient is on insulin or sulphonylurea consider an infusion of 5% glucose 100 ml/hour.5 mmol/litre to avoid arrhythmias. This remains unclear. Start oral hypoglycaemics for patients with T2DM and the usual insulin regime for patients with T1DM with the first meal. and it is usually the co-morbidities of patients with diabetes that limit their suitability as day cases. In these cases.’ Eight hours fasting and prokinetic therapy is recommended in patients whose HbA1c levels exceed 9%. diabetes is not an independent factor for increased morbidity or mortality after ambulatory surgery. Regional anaesthesia Regional anaesthesia can reduce the stress response and avoids intubation. Potassium should be checked frequently and kept at 4–4. Regional anaesthesia is associated with decreased blood loss and decreased thromboembolic complications. Controversies Wright et al. Minor day surgery consists of procedures that allow oral intake in the first hour after surgery. until they are ready for a meal. The normal insulin doses can be given once the patient is eating. Patients treated by oral hypoglycaemics whose blood glucose on admission is below 10 mmol/litre can just be observed but patients with blood glucose levels above 10 mmol/litre and all patients taking insulin should be treated with a GIK infusion. should be first on the list and aim to have early food intake postoperatively.Endocrinology Patients with T1DM have half of their usual morning dose of short.or intermediate-acting insulin. An alternative to a GIK regime would be the in-hospital administration of half of the patient’s morning dose as an intermediate duration insulin in combination with perioperative tight glucose control and the use of short-acting insulin to treat hyperglycaemia.
102: 904–9. which can make it necessary to change the whole infusion if the blood glucose is out of range. neurologic complications after neuraxial anesthesia or analgesia in patients with preexisting peripheral sensorimotor neuropathy or diabetic polyneuropathy. et al. Anesth Analg 2005.gov. Anesth Analg 2006. neurologic complications after neuraxial anesthesia or analgesia in patients with preexisting peripheral sensorimotor neuropathy or diabetic polyneuropathy. diabetes: anaesthetic management. such as Hartmann’s solution. AnAESTHESiA And inTEnSiVE cArE MEdicinE 9:10 445 © 2008 Elsevier ltd. Anesthesiology 2005. The infusion could contain low glucose concentrations of 10–20%. 103: 1294–9. Anaesthesia 2006. 61: 1187–90. 100: 666–9. ◆ 2 British Association of day Surgery. Am J Med Sci 1985. 3 Wright rA. leading to a huge amount of free water. day surgery and the diabetic patient: guidelines for the assessment and management of diabetes in day surgery patients. or 50%. lactate-containing solutions. The diabetic surgical patient. which creates the danger of one part being stopped accidentally resulting in hyperor hypoglycaemia. 289: 240–2. May 2007. All rights reserved. Wathen r. These authors concluded that the risk of severe postoperative neurological injury in patients with pre-existing peripheral sensorimotor neuropathy or diabetic polyneuropathy undergoing neuraxial anaesthesia or analgesia is relatively uncommon.Endocrinology existing polyneuropathy could show an incidence of progression of neurological symptoms in 0. it can be run as a separate insulin infusion and a glucose–potassium infusion. There is no clear evidence for the optimal intravenous fluid for patients with diabetes. . 6 Hebl JA. Clinicians should be aware of this potentially high-risk subgroup. Advances in diabetic management: implications for anaesthesia. london: BAdS. 19: 339–45. 5 robertshaw HJ. the risk appears to be higher than in the general population. 4 Jellish WS. diabetes: anaesthetic management. diabetic gastroparesis: an abnormality of gastric emptying of solids. day surgery and the diabetic patient: guidelines for the assessment and management of diabetes in day surgery patients. seem to be safe. which can be given only through a central line. Zufiqar A.dh. Vivek K. Anesth Analg 2006. Effect of metoclopramide on gastric fluid volumes in diabetic patients who have fasted before elective surgery.4% out of 567 patients. It was unclear whether or not the neuraxial block was the cause of it. 61: 1187–90. 2004. uk/en/Healthcare/nationalServiceFrameworks/diabetes/dH_074762 FuRTHeR ReADInG British Association of day Surgery. Curr Opin Anaesthesiol 2006. clemente r. Anaesthesia 2006. Hebl JA. london: BAdS. Glucose–insulin–potassium regime There are generally two ways to run a GIK scheme. However. http://www. It can be run as one infusion including all three components. 103: 1294–9. Alternatively. robertshaw HJ. However. 2004. The administration of solutions containing only glucose run the risk of hyponatraemia due to overload of free water. ReFeRenCeS 1 department of Health About diabetes.
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