This action might not be possible to undo. Are you sure you want to continue?
Standard Assessment including an elaborate history, physical examination and treatment history Specific attention towards recognizing complications of Diabetes
• ECG • Urinalysis for detecting sugar and ketones • CBC, serum electrolytes, urea nitrogen, sugar and ketones
(serum osmolality if available), HbA1C
• ABG analysis to determine acid–base status
• Best marker for recent control • Levels less than 7% indicate good control • Levels over 9% and particularly 12%, indicate poor control
and likely to be associated with electrolyte and water loss
Autonomic Neuropathy • Autonomic dysfunction is detectable in up to 40% of type 1 diabetics • Typical symptoms and signs of postural hypotension. gastroparesis. gustatory sweating and nocturnal diarrhoea • The easiest way is to assess heart rate variability The normal heart rate should increase by over 15 beats/minute in response to deep breathing Neuropathy is likely if there is less than 10 beats/minute increase .
especially if considering a regional technique . Peripheral Neuropathy • Commonest type is the “glove and stocking” type • Diabetics are also prone to mononeuritis multiplex and some particularly painful sensory neuropathies • Poor patient positioning is more likely to result in pressure sores that are often slow to heal • Documentation of existing neuropathy is prudent.
cardiomyopathy and perioperative myocardial infarction • Ischaemia may be „silent‟ as a result of neuropathy Routine ECG should be performed and appropriate stress testing if in doubt • Autonomic neuropathy can result in sudden tachycardia. hypertension. bradycardia. PVD. cerebrovascular disease. Cardiovascular • Diabetics are more prone to IHD. postural hypotension and profound hypotension after central neuraxial blockade .
Respiratory • Diabetics. humidified oxygen and bronchodilators should be considered . are more prone to respiratory infections and might also have abnormal spirometry • Chest physiotherapy. especially the obese and smokers.
at least 2 hours preoperatively . Gastrointestinal • Gastroparesis can increase the risk of aspiration • Always ask about symptoms of reflux and consider a rapid sequence induction even in elective procedures • If available prescribe an H2 antagonist such as Ranitidine 150 mg plus Metoclopramide 10 mg.
as if praying. anticipate difficulty in intubation . and simultaneously hyperextend to 90 degrees at the wrist joint If the little fingers do not oppose. Airway • Glycosylation of collagen in the cervical and temporo- mandibular joints can cause difficulty in intubation • Prayer Sign Ask patient to bring the hands together.
creatinine and electrolytes Potassium is important in view of the possible need for Suxamethonium for Rapid Sequence Intubation • Ensure adequate hydration to reduce postoperative renal dysfunction . Renal • Diabetes is one of the commonest causes of end-stage renal disease • Check urea.
Immune system • Diabetics are prone to all types of infection • Tight glycaemic control will reduce the incidence and severity of infections .
Hydration • Poor oral intake secondary to malaise and abdominal pain. concomitant vomiting and osmotic diuresis resulting from glucosuria make dehydration quite likely • Normal or half-normal saline is a preferred intravenous solution Glucose Control Antibiotics .
High levels can promote non-enzymatic glycosylation reactions forming abnormal proteins • Weaken endothelial junctions and decrease elastance • Responsible for the stiff joint syndrome and decreased wound- healing Elevations in glucose may increase macroglobulin production by the liver and promote intracellular swelling Glycemia also disrupts autoregulation .
The key to managing BGL perioperatively is to set clear goals and then monitor BGL frequently enough to adjust therapy to achieve Might be influenced by • Type of surgery • Bias of the patient's primary care physician • Type of diabetes .
infuse a solution of i. ketoacidosis and hyperosmolar states Protocol: • On the day before surgery. give half the usual morning insulin dose (and the usual type of insulin) subcutaneously Continue 5% dextrose solutions through the operative period and give at least 125 mL/hr/70 kg body weight In the recovery room. the patient should be NPO after • • • • midnight At 6 AM on the day of surgery. Aim: To prevent hypoglycemia.v. fluids containing 5% dextrose at a rate of 125 mL/hr/70 kg body weight After starting the intravenous infusion. monitor blood glucose concentrations and treat on a sliding scale .
v. Aim: To keep plasma glucose levels at 79 to 120 mg/dL Protocol: • On the evening before surgery. determine the preprandial BGL • Begin an i.9% sodium chloride) to the dextrose infusion with an infusion pump • Set the infusion rate by using the equation: Insulin (U/hr) = plasma glucose (mg/dL)/150 . infusion of 5% dextrose at a rate of 50 mL/hr/70 kg body weight • „Piggyback‟ an infusion of regular insulin (50 units in 250 mL or 0.
• Repeat blood glucose measurements every 4 hours as needed and adjust insulin appropriately to obtain blood glucose levels of 100 to 200 mg/dL • On the day of surgery. intraoperative fluids and electrolytes are managed by continued administration of non–dextrosecontaining solutions • Determine the plasma glucose level at the start of surgery and every 1 to 2 hours for the rest of the 24-hour period and adjust the insulin dosage appropriately .
Avoid hypoglycaemia (under 50 mg/dl) as this can cause irreversible cerebral damage Avoid severe hyperglycaemia (over 250 mg/dl) to minimise dehydration and metabolic upset Type 1 diabetics need insulin to prevent ketogenesis Aim for a blood glucose between 100 and 180 mg/dl Diabetic patients should be placed first on the operating list to shorten the preoperative fast and potentially allow normal oral intake later that same day Tight metabolic control is important for both type 1 and type 2 patients .
Continue all diabetic medication until the day of surgery except • Chlorpropamide (stop 3 days prior as long acting. substitute with a shorter acting sulphonylurea) • Metformin (only if major surgery as risk of lactic acidosis ) • Glitazones • Long acting insulin – substitute with short/intermediate acting Measure blood sugar preoperatively – 4 hourly if on insulin. 8 hourly if not .
splanchnic or other regional blockade may modulate secretion of catabolic hormones and any residual insulin secretion Patients undergoing surgery with neural blockade will usually resume oral intake earlier than after general anesthesia At present. epidural. Use of spinal. there is no evidence that RA alone or in combination with GA confers any benefit in terms of mortality and major complications .
RA may carry greater risks in the diabetic patient with autonomic neuropathy • Profound hypotension may occur in a patient with co-existing coronary artery. cerebrovascular or renovascular disease The risks of infection and vascular damage may be increased with the use of regional techniques in diabetic patients • Epidural abscesses occur more commonly following spinal and epidural anesthesia .
enflurane and isoflurane inhibit the insulin response to glucose in a reversible and dose-dependent manner . but also hormonal and metabolic stability • Effectively block the entire sympathetic nervous system and the hypothalamic-pituitary axis • Abolition of catabolic hormonal response to surgery will abolish hyperglycemia seen in normal patients and may be of benefit Halothane. High-dose opiate anesthetic techniques produce not only hemodynamic.
The effect of propofol on insulin secretion is not known • Diabetic patients show a reduced ability to clear lipids from the circulation • May have implications for patients receiving propofol for prolonged sedation in the ICU .
Continuous monitoring: • Pulse oximetry • Electrocardiogram • Blood pressure • Capnography (if under GA) • Temperature • Urine output (if catheterized) Blood glucose estimation as needed .
reduced cholestasis. in-hospital mortality and morbidity than patients who were tightly controlled (80–110 mg/dl) • Better neutrophil and macrophage function. enhanced erythropoiesis. Aggressive insulin therapy in the ICU has demonstrated significant benefit in morbidity and mortality Patients receiving conventional insulin therapy (180–200 mg/dl) demonstrate significantly higher rates of ICU mortality. beneficial changes to mucosal/skin barriers. improved respiratory muscle function and decreased axonal degeneration .
The postoperative management of diabetics requires meticulous monitoring of insulin requirements The predischarge 24-hour inpatient insulin requirement should be compared to the preoperative outpatient insulin dose To determine the discharge dose. it is usually given once at bedtime If the patient takes intermediate-acting insulin twice daily.or rapid-acting insulin If glargine is prescribed. the total insulin dose for the most recent 24-hour period is calculated and 50% of the discharge dose is prescribed as long. then two thirds of the dose should be taken in the morning and one third at bedtime .or intermediate-acting insulin and 50% as short.
significant dehydration. gastrointestinal obstruction or trauma • Patients present with hyperglycemia. vomiting. hyperosmolarity. Diabetic Ketoacidosis • DKA is more likely to develop in type 1 diabetics and is usually precipitated by infection. ketosis and acidosis • Severe dehydration is secondary to osmotic diuresis. hyperventilation. and reduced oral intake • Total body deficits of sodium and potassium are present and frequently phosphate and magnesium deficits exist .
10– 40 mEq/hr (with continuous ECG monitoring when the rate is >10 mEq/hr) • When serum glucose decreased to <250 mg/dL.10. anticipate 4– 10 L deficit • When urine output is >0.v. fluids as guided by vital signs and urine output. 10 U i. add Dextrose 5% at 100 mL/hr • Sodium bicarbonate is not routinely given and is reserved for cases where the pH is less than 7. give potassium chloride.v.• Regular insulin. bolus. .5 mL/kg/hr. followed by an insulin infusion nominally at (blood glucose/150) U/hr • i.
Hyperosmolar Hyperglycemia State • HHS usually occurs in elderly. hyperosmolar (> 320 mOsm/L) and hyperglycemic (> 800–1000 mg/dl) • They may present with confusion. seizures or coma • Electrolyte deficits are less severe than in DKA . debilitated type 2 diabetics • These patients present with greater metabolic derangements than those with DKA and are severely dehydrated . focal central nervous system deficits.
• Treatment consists of larger volumes of normal saline and similar doses of insulin compared to patients with DKA • These patients are at significant risk of developing cerebral edema and therefore correction of serum glucose and osmolarity should proceed gradually over a 12.to 24-hour period .
these signs of sympathetic hyperactivity can be easily misinterpreted as inadequate or “light” anesthesia • In patients being treated with β-adrenergic blocking agents or in patients with advanced diabetic autonomic neuropathy. the sympathetic hyperactivity of hypoglycemia may be obscured . produces CNS changes ranging from light- headedness to coma with seizures • There is a reflex catecholamine release that produces overt sympathetic hyperactivity causing tachycardia. lacrimation. Hypoglycemia • Defined as a serum glucose less than 50 mg/dl in adults and 40 mg/dl in children • In the awake patient. diaphoresis and hypertension • In the anesthetized patient.
the action of insulin and oral hypoglycemic agents is prolonged .• Treatment is with 25 g of intravenous dextrose (1 amp of dextrose 50%) or 1 mg of intramuscular glucagon • Hypoglycemia is more likely to occur in the diabetic surgical patient if insulin or sulfonylureas are given without supplemental glucose • With renal insufficiency.
McGill JB. Insulin: understanding its action in health and disease. Perioperative care of the diabetic patient. et al. Sonksen P. 74:346–359 . Coursin DB. Clinical management of diabetes mellitus during anaesthesia and surgery. Ketzler JT. Update in Anaesthesia 2000. Br J Anaesth 2000. 85: 69-79 McAnulty GR. Perioperative management of surgical patients with diabetes mellitus. ASA refresher courses in anesthesiology. Sonksen J. 85: 80-90 French G. Robertshaw HJ. Anesthesiology 1991. 11: Article 13 Angelini G. Cryer PE. Br J Anaesth 2000. Anaesthetic management of patients with diabetes mellitus. Park Ridge: American Society of Anesthesiologist. Hall GM. 2001:1–10 Hirsh IB.
This action might not be possible to undo. Are you sure you want to continue?
We've moved you to where you read on your other device.
Get the full title to continue reading from where you left off, or restart the preview.