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Perioperative Management of DM and HTN

. ACC/AHA guideline update on perioperative cardiovascular evaluation for non cardiac surgery. A

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Perioperative Management of DM and HTN

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    1. Perioperative Management of DM and HTN Present by Ri ???

    2. ACC/AHA guideline update on perioperative cardiovascular evaluation for non cardiac surgery. A&A 2002;94: 1052-1064

    6. Maintaining Glycemic Control Insulin: 1. Stimulates glucose uptake and utilization by muscle and fat tissue. 2. Suppresses hepatic glucose production from gluconeogenesis and glycogenolysis. 3. Prevents development of ketosis and protein breakdown. Counterregulatory hormones: glucagon, epinephrine, cortisol, and growth hormone. During the perioperative period, adequate insulin prevent metabolic decompensation.

    7. Perioperative Response to Surgery and Anesthesia (I) Neuroendocrine stress response with release of counterregulatory hormones. 1. peripheral insulin resistance, 2. increased hepatic glucose production, 3. impaired insulin secretion, 4. fat and protein breakdown, 5. potential hyperglycemia and even ketosis in some cases.

    8. Perioperative Response to Surgery and Anesthesia Fasting and volume depletion contribute to metabolic decompensation. Type I DM: Diabetic ketoacidosis may develop in the absence of severe hyperglycemia because of inadequate insulin availability during a time of increased demand Type 2 DM: Hyperglycemic hyperosmolar nonketotic states Infection Wound healing Local and epidural anesthesia: minimal effect

    9. Preoperative Evaluation Metabolic control and any diabetes-associated complications Cardiovascular disease: resting ECG, stress test Cardiac autonomic neuropathy: may predispose patients to perioperative hypotension; the presence of resting tachycardia, orthostatic hypotension, peripheral neuropathy, and loss of normal respiratory heart rate variability should be sought. Renal dysfunction: serum creatinine, 24hr Ccr, proteinuria or abnormal creatinine clearance have a greater risk of developing acute renal failure.

    10. GLYCEMIC CONTROL Patients taking insulin, 1. Long-acting insulin: discontinued 1~2 days before surgery -> intermediate or short-acting insulin 2. Exception: well-controlled and using glargine.

    11. Glycemic control Patient taking OHA: generally discontinued, due to fasting 1. Long-acting sulfonylureas:stopped 48 to 72 hours before surgery 2. Short-acting sulfonylureas, other insulin secretagogues, and metformin withheld the night before or the day of surgery. 3. No recommendations for discontinuation of thiazolidinediones (e.g. rosiglitazone [Avandia], pioglitazone [Actos]) 4. Good metabolic control, minor surgery: antihyperglycemic treatment may not be needed on the day of surgery. Otherwise, insulin will generally be used. 5. Metformin: withheld when radiographic contrast

    12. Evaluation for emergency surgery

    13. Intraoperative Management All need insulin except well-control (fasting glucose<140) and short surgery IV insulin infusion: more effective and predictable (High epinephrine level in subcutaneous tissue: absorption of insulin is unreliable) Target range: 120-180 mg/dL Type I DM: start rate: 0.5-1U/hr Poor control or Type II DM: 2-3U/hr

    15. Intraoperative management Contineous glucose-insulin-potassium infusion: 500ml 10% dextrose + 15U RI + 10 mmol KCL set rate 100ml/hr; B/G per 2 hours 117-200mg/dL: usual GKI: >200mg/dL:20U RI <117mg/dL:10U RI Elderly or heart failure: run for 6-8 hours or double the dextrose to 20% One half the usually dose of long or intermediate-acting insulin SC injected in the morning of surgery

    16. Intraoperative management Check sugar as often as feasible (every 1-2 hr) Slow glucose infusion (i.e., 100 to 125 mL per hour in 5 percent dextrose) to prevent hypoglycemia, ketosis, or protein breakdown. Continuous glucose monitoring system Well control, no insulin: if sugar>180~200, start insulin Obesity, sepsis, steroid administration, poor preoperative metabolic control, and recent ketoacidosis also increase perioperative insulin requirements.

    17. GLUCOSE, FLUID, AND ELECTROLYTE MANAGEMENT 5 g of glucose per hour for basal energy requirements and to prevent hypoglycemia, ketosis, and protein breakdown during surgery. More glucose may be needed if conditions are very stressful. 1. Short procedures: 5% dextrose : 100 mL per hour 2 Longer procedures: 10% dextrose: 50 mL per hour 3. 20 or 50% through a central line if fluid restriction is critical.

    18. GLUCOSE, FLUID, AND ELECTROLYTE MANAGEMENT Normal serum potassium level does not necessarily reflect a normal total body potassium concentration. Potassium into cells: Insulin and epinephrine Potassium out of cells: hyperosmolarity causes, acidosis. DM patient with normal renal function and serum potassium levels, 10 to 20 mEq per L of potassium should be added per liter of dextrose-containing fluid. More potassium is given if hypokalemia is present. In patients with hyperkalemia, potassium is not given unless the level falls into the normal range.

    19. Postoperative Management Sliding scale tend to promote swings in glucose control—high and low. Never be the sole insulin administration regimen in patients with type 1 diabetes because the development of diabetic ketoacidosis is possible before significant hyperglycemia is present. It is important to remember that patients with type 1 diabetes have basal insulin requirements that must be met, even during fasting, to maintain metabolic control.

    20. Postoperative Management Insulin infusion until resume solid food intake. Continuing the insulin infusion while patients are on a liquid diet is preferable. Check insulin every one or two hours Check electrolyte daily as long as insulin infusion continues Patient’s usual dose of morning subcutaneous insulin can be given before the breakfast and lunch, and the infusion can be discontinued two hours later.

    21. Conclusion Surgical outcomes are improved in patients with diabetes who are maintained in good metabolic control. Little data are available to allow specifying optimal treatment for perioperative management of diabetes. Physicians must be cognizant of patients’ preoperative control, their relative need for insulin, and any factors that may be likely to increase insulin requirements.

    22. Conclusion When insulin requirements are in doubt, it is better to err on the side of providing rather than withholding insulin. The administration of adequate glucose in conjunction with the judicious use of insulin will prevent hypoglycemia. DKA, NKHS, are not so easily managed. The key to success frequent monitoring of glucose, electrolyte, and fluid levels, and acid-base status. Prevention of surgical complications as a result of hyperglycemia is possible with meticulous perioperative glucose management.

    23. Perioperative management of Hypertension

    24. Perioperative management of Hypertension Numerous studies have shown that stage I or II HTN( SBP<180, DSP<110 mmHg) are not independent risks for perioperative CV complications ? no need to delay surgery or escalation in medical therapy

    25. Perioperative management of Hypertension Severe HTN (SBP>180, DSB>110) ?some but weak evidence ? JNC-VI recommends delay elective surgery when DSP>110) ?reduce BP slowly (6-8 weeks) for fear of increasing M&M secondary to secondary to critical coronary or carotid arterial stenosis. Isolated systolic HTN(SBP>160, DSP<90), one study showed 30% increase of cardiovascular complications

    26. End organ damage and perioperative outcome Occult CAD (Q wave on ECG) CHF (symptoms and signs) LVH (ECG voltage criteria) Renal insufficiency (creatinine>2.0) Cerebrovascular disease (hx of CVA and TIA)

    27. Treatment of HTN Generally, antihypertensive drug should be continued during the perioperative peroid. Abrupt discontinuation of ß-blocker ?perioperative tachycardia Withdrawal of clonidine ?rebound HTN ACEI and Angiotensin II inhibitor?held in the morning of surgery

    28. Perioperative medical therapy Class I 1. Beta-blockers required in the recent past to control symptoms of angina or patients with symptomatic arrhythmias or hypertension. 2. Beta-blockers: patients at high cardiac risk owing to the finding of ischemia on preoperative testing who are undergoing vascular surgery. Class IIa 1. Beta-blockers: preoperative assessment identifies untreated hypertension, known coronary disease, or major risk factors for coronary disease.

    29. Perioperative medical therapy Class IIb 1. Alpha-2 agonist: perioperative control of hypertension, or known CAD or major risk factors for CAD. Class III 1. Beta-blockers: contraindication to beta-blockade. 2. Alpha-2 agonists: contraindication to alpha-2 agonists.

    30. References ACC/AHA guideline update on perioperative cardiovascular evaluation for non cardiac surgery. A&A 2002;94: 1052-1064 Perioperative management of Diabetes. American family physician, Jan 1, 2003 Preoperative evaluation of the patient with hypertension. JAMA, vol 287 Np.16 April 24, 2002 The sixth report of the Joint National Committee on prevention , evaluation, and treatment of high blood pressure. Arch Intern Med. 1997; 157:2413-2446

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