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Manajemen Pre-Operatif

pasien dengan DM

Manifestasi Klinis DM
Diabetes mellitus ditandai oleh ganguan
metabolisme karbohidrat yang disebabkan
oleh defisiensi insulin atau menurunnya
kemampuan reaksi insulin, yang
menimbulkan hiperglikemi dan glukosuria.
Diagnosis berdasarkan peningkatan fasting
glukosa plasma ( > 140 mg/dl ) atau fasting
glukosa darah ( > 126 mg/dl )

>>>>>>>>Morgans clinical anesthesiology, 4th edition

Pre-operative Assessment
Airway
thickening of soft tissues (glycosylation)
occurs, especially in ligaments around joints
limited joint mobility syndrome.
Intubation may be difficult if the neck is
affected or there is insufficient mouth
opening.

Respiratory
diabetics are prone to perioperative chest
infections, especially if they are obese and
smokers.
>>>>>>Oxford American Handbook of Anesthesiology

Pre-operative Assessment
Cardiovascular
the diabetic is prone to hypertension,
ischemic heart disease (may be silent),
cerebrovascular disease, myocardial
infarction, and cardiomyopathy.
Autonomic neuropathy can lead to tachyor bradycardia and postural hypotension.

>>>>>>Oxford American Handbook of Anesthesiology

Pre-operative Assessment
Renal
40% of diabetics develop
microalbuminuria, which is
associated with hypertension,
ischemic heart disease, and
retinopathy. This may be reduced by
treatment with ACE inhibitors.

>>>>>>Oxford American Handbook of Anesthesiology

Pre-operative Assessment
Gastrointestinal
50% have delayed gastric emptying
and are prone to reflux.
Diabetics are prone to infections

>>>>>>Oxford American Handbcook of Anesthesiology

Diabetic Autonomic
Neuropathy

Pasien DM dengan HT, 50% beresiko terhadap


diabetic autonomic neuropathy
Tanda Klinis :

Hypertension
Painless myocardial ischemia
Orthostatic hypotension
Lack of heart rate variability1
Reduced heart rate response to atropine and
propranolol
Resting tachycardia
Neurogenic bladder
Lack of sweating
Impotence
>>>>>>>>Morgans clinical anesthesiology, 4th edition

Preoperative Glucose
Management
Because good evidence is lacking to
be able to set standards for the
perioperative glucose management
of diabetic patients, at a minimum,
an attempt should be made to
control the glucose within a range of
100 to 200 mg/dL, although some
will argue that tighter control with a
top limit of 150 mg/dL is warranted
>>>>>>>>>>>>Barash Clinical Anesthesia,

Recommendations
Plan with the surgeon to schedule the surgery as
the first case of the day to prevent prolonged
fasting.
As a general rule, oral hypoglycemic agents are
held on the day of surgery to avoid reactive
hypoglycemia. The exception is metformin,
which should be held for at least 24 hours
preoperatively to avoid the risk drug-induced
lactic acidosis.
Insulin should be continued through the evening
before surgery, including the usual dose of
insulin glargine (Lantus).
>>>>>>>>>>>>Barash Clinical Anesthesia,

Recommendations
Patients should be counseled to take a
glucose tablet or clear juice if
hypoglycemia occurs prior to arrival at
the hospital, in order to prevent delay
of the surgery.
Schedule the patient to arrive without
having ingested anything by mouth in
early morning and check blood
glucose, electrolytes, and ketones.
>>>>>>>>>>>>Barash Clinical Anesthesia,

Recommendations
Type 1 diabetics should be continued
on basal insulin replacement even
while nothing by mouth status to
prevent ketoacidosis. Administer half
the usual morning dose of
intermediate- or long-acting insulin
after arrival to the surgery center,
but hold the usual dose of rapid- or
short-acting insulin.
>>>>>>>>>>>>Barash Clinical Anesthesia,

Recommendations
Patients on insulin pumps may be
managed by continuing the pump for
short surgeries, or changing over to
an intravenous insulin infusion for
moderate or major surgeries.
Use the patient's own sliding scale to
administer a short-acting insulin
subcutaneously to maintain the
glucose between 100 and 200 mg/dL
prior to the scheduled surgery
>>>>>>>>>>>>Barash Clinical Anesthesia,