DIABETIC AND

RESPIRATORY
DRUGS
Kelompok 5:
Adhitya Wisnu Mahadewa
Musthafa Afif Wardhana
Mochammad Ecky Pratama
Irma Kusumawati
Kasus Bedah Elektif
Pada Pasien DM
 Mengapa komorbid DM penting
dipertimbangkan dalam persiapan op?
Surgery-related morbidity and mortality generally fall into
one of three categories: cardiac, respiratory and infectious
complications

The overall risk for surgery-related complications depends

on individual factors and the type of surgical procedure.

Advanced age places a patient at increased risk for

surgical morbidity and mortality.

Diseases associated with an increased risk for surgical

complications include respiratory and cardiac disease,
malnutrition and diabetes mellitus
The Charlson comorbidity index

the potential importance of

comorbidity as a determinant
of outcome and resource use.
The weight of secondary
diagnoses (comorbidities)
present greater risk than others
 Efek tindakan operasi terhadap status
GD pasien DM
Metabolic effects of starvation:
◦ 1. Period of starvation induces a catabolic state.
◦ 2. It will stimulate secretion of counter-regulatory hormones .
◦ 3. It can be attenuated in patients with diabetes by infusion
of insulin and glucose (approximately 180g/day).

Metabolic effects of major surgery.

◦ It causes neuroendocrine stress response with release of
counter- regulatory
◦ hormones (epinephrine, glucagon, cortisol and growth
hormone) and of
◦ inflammatory cytokines IL-6 and tumor necrosis factor-
alpha.
◦ Hypoglycaemia – exacerbate the catabolic effect of
surgery
◦ These neuro hormonal changes result in metabolic
abnormalities including
Increased insulin resistance.
decreased peripheral glucose utilization.
impaired insulin secretion.
increased lipolysis .
protein catabolism, leading to  hyperglycemia
and even ketosis in some cases
KADAR GD YANG AMAN UNTUK DILAKUKAN
TINDAKAN OPERASI

Target BG range for perioperative

period should be 80-180 mg/dl
(Standards of Medical Care in Diabetes, 2017)
 KONTROL GD PRE OP

Konsensus penggunaan insulin Perkeni (2015)

Konsensus penggunaan insulin Perkeni (2015)
 EFFICACY dan SAFETY ISSUE Insulin
• Insulin therapy reaction : Sulphonylureas 
hypoglycemia, Metformin  lactic acidosis, Incretins &
amylin  delays gastric emptying , nausea
Target Blood Sugar is 80-110 mg/dl.
• Indications: Pregnancy, CPB, Neurosurgery.
• Advantages: Improve wound Healing, Prevent wound
infection, Improve neurological outcome.
• Night before surgery do preprandial glucose.
• Start 5% Dextrose @ 50 ml/hr.
• Dissolve 50 U of insulin in 250 ml of NS and start piggy
back infusion.
• Insulin infusion rate is adjusted by BG/150 U per hr and
BG/100 U per hr if pt is obese or on steroid or in sepsis.
BAGAIMANA KONTROL GD INTRA OP DAN POST OP
(JIKA PASIEN SEDANG MENGKONSUMSI OAD)

Konsensus Pengelolaan dan Penceghan Diabetes Melitus (2015)

 PROFIL FARMAKOLOGI INSULIN

Konsensus Pengelolaan dan Penceghan Diabetes Melitus (2015)

KASUS BEDAH ELEKTIF PADA PASIEN
DENGAN KELAINAN RESPIRASI
(SEDANG MEMAKAN OBAT UNTUK
PENYAKIT SAL NAFAS KRONIK DAN
TERKAIT GANGGUAN FUNGSI
KAPASITAS PARU)
 KENAPA INI PENTING DIBAHAS? TERKAIT
OBAT DAN KONDISI PARU-NYA?

COPD  high risk for atelectasis, pneumonia

and death post surgery.
Anesthetic agents  impaired chest wall
coordination that facilitates breathing
(diaphragm muscles, intercostal muscles, and
abdominal muscles).
Anesthetic induction  decrease KRF which can
trigger atelectasis
Upper airway reflex disorders  prolonged period of intubation
or reversal disorder of neuromuscular blockade thereby
increasing the risk of aspiration and pneumonia especially in
elderly patients

In COPD patients who smoke, there is already disruption of lung

defense mechanisms against infections such as mucosilier
transport disturbances and alveolar macrophage function 
Anesthesia and surgery may aggravate the disorder.

Airway manipulation can lead to bronchospasm.

The combination of these factors with postoperative atelectasis

and reflex cough reflexes due to respiratory muscle dysfunction
may trigger the onset of PPC
Apa dampak pasien dengan penyakit
paru (kronik) jika mengalami operasi?
VENTILATION
◦ Opioid can produce profound respiratory
depression
◦ The inhalational anaesthetics halothane,
enflurane, and isoflurane also depress
respiratory drive
LUNG VOLUMES
◦ Functional residual capacity is reduced during
GA by about 20% below the value measured
in the awake, supine position
◦ The diaghragm ascended into the chest by
about 2 cm during anaesthesia with/without
paralysis  paralisis diafragma unilateral
GAS EXCHANGE
◦ V/Q mismatch
◦ elimination of CO (changes in the ratio of
dead space to tidal volume)
 PERSIAPAN YANG PERLU DILAKUKAN
SEBELUM TINDAKAN OPERASI
Perioperative managements :
- General physical (history of lung, heart, and neurologic
disease) and therapy of reversible symptoms and signs
- Reversible lung pathology can be treated with antibiotics,
bronchodilators, corticosteroids, and so on. The general
principle is the function of the lungs should be in the optimal
state according to the standard Chest X-ray is required for
symptom evaluation.
- Blood gas analysis is only when necessary, the indication is if
VEP1 and KVP <50%, Patients with COPD usually experience
a decrease in PaO2 and an increase in PaCO2 indicating
alveolar hypoventilation
- In patients who smoke, decreased postoperative
complications are said to be significant if they quit smoking
for 6 weeks preoperative
 PRE OP DAN DURANTE OP JIKA PASIEN SEDANG
MENGKONSUMSI OBAT2AN BRONKODILATOR
(SALBUTAMOL, AMINOFILIN,STEROID, MUKOLITIK)
 PRE OP DAN DURANTE OP JIKA PASIEN SEDANG
MENGKONSUMSI OBAT2AN BRONKODILATOR
(SALBUTAMOL, AMINOFILIN,STEROID, MUKOLITIK)

Smoking should be stopped patient at risk for developing

at least 2 months before complications or having a pre-
elective surgery to decrease operative FEV1 <80% to receive
carboxy-Hb levels and oral steroids. The drugs
improve mucociliary recommended are oral
clearance of sputum prednisone 40–60 mg/day or IV
hydrocortisone 100 mg/8 hourly

Pre-operative optimisation of lung function Naheed Azhar. Indian J Anaesth2015 Sep; 59(9): 550–556.
TEKNIK PEMILIHAN OBAT ANESTESI PADA PASIEN
DENGAN PENYAKIT SAL. NAFAS (KRONIS)
The classical clinical features of COPD patients can be
divided into two:
1. 'pink puff ers'  breathing stimulants and PaCO2 values
is normal ,
2. 'blue bloaters‘  decreased breathing excitement and
CO2 retention.

The anesthesia approach is adapted to the patient's clinical

condition, surgical plan, and clinical setting. A shorter period
of surgery helps reduce the risk of complications.
To overcome airway inflammation  given inhaled β2-
adrenergic or anticholinergic agonists preoperatively, especially
if planning tracheal intubation.
Tracheal intubation can be avoided by using laryngeal mask or
the like, if possible.

Propofol, ketamine, or volatile anesthetics are the preferred

induction agents, whereas barbiturates can sometimes
stimulate bronchospasm.

Additional agents to increase the depth of anesthesia and

collect reflux airway reflexes prior to intubation (lidocaine or
opioid) may be helpful.
Administration of laryngotracheal lidocaine is not recommended
as it may increase airway resistance. A volatile anesthetic agent
may be helpful in maintenance of anesthesia because it has a
bronchodilating effect, except desfl urane.
 PENGELOLAAN POST OP SUPAYA PENYAKIT SAL
NAFAS KRONIK TIDAK MEMBURUK
Nasogastric decompression

Nasogastric decompression after abdominal surgery is done to

treat postoperative nausea and vomiting, eating disability, or
symptomatic abdominal distension, reducing the risk of
pneumonia and atelectasis without affecting gastric function
parameters. Nasogastric drainage increases the risk of silent
bronchoaspiration so it should be selective.

Pulmonary expansion method/Lung Expansion Methods

The use of extrinsic PEEP reduces the effect of PEEPi and
respiratory work when mechanical controlled ventilation of
COPD patients. The use of postabsor- tant extrinsic PEEP with
CPAP will also reduce the difference between alveolar pressure,
upper airway pressure and PEEPi level
Thank you