Diabetes mellitus anesthetic implications including perioperative glycemic control
This presentation is the property of its rightful owner.
Sponsored Links
1 / 32

Diabetes Mellitus & Anesthetic Implications, Including Perioperative Glycemic Control PowerPoint PPT Presentation


  • 88 Views
  • Uploaded on
  • Presentation posted in: General

Diabetes Mellitus & Anesthetic Implications, Including Perioperative Glycemic Control. www.anaesthesia.co.in [email protected] outline. Definition, diagnosis & classification Pre op systematic evaluation Over view of anesthetic techniques Pharmacology of insulin &OHA

Download Presentation

Diabetes Mellitus & Anesthetic Implications, Including Perioperative Glycemic Control

An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -

Presentation Transcript


Diabetes mellitus anesthetic implications including perioperative glycemic control

Diabetes Mellitus & Anesthetic Implications, Including Perioperative Glycemic Control

[email protected]


Outline

outline

  • Definition, diagnosis & classification

  • Pre op systematic evaluation

  • Over view of anesthetic techniques

  • Pharmacology of insulin &OHA

  • Peri op glycemic control


Definition who

Definition ( WHO)

Diabetes mellitus -

A metabolic disorder of multiple etiology characterized

by chronic hyperglycemia with disturbances of

carbohydrate, fat and protein metabolism

resulting from defects in insulin secretion, insulin action

or both.


Classification pathophysiology and prevalence of dm who ada

Classification, Pathophysiology and Prevalence of DM (WHO / ADA)


Revised diagnostic criteria for diabetes mellitus

Revised diagnostic criteria for diabetes mellitus


Preoperative evaluation risk assessment

Preoperative evaluation &risk assessment

Classical diabetic complications

Macroangiopathy - arteriosclerosis

Microangiopathy - heart, kidney &retina

Autonomic neuropathy - heart,GI &urinary tracts

Collagen anomalies - respiratory tract & joints

Unifying hypothesis - impaired glycosylation of proteins

Systematic search of diabetic complications - key step


Cardio vascular risk assessment

Cardio vascular risk assessment

  • Major disturbances

    Coronary artery disease

    Arterial HTN

    Impaired LV function

    Cardiac dysautonomy

    Sudden death


Diabetic coronary artery disease

Diabetic coronary artery disease

  • Intermediate clinical predictor (ACC/AHA)

  • Cardiac event rate - 2.5% / year

  • 2 fold increased in mortality

  • Silent ischemia

  • Screening asymptomatic patients ? ?

    appropriate for high risk patients.


Systemic arterial htn

Systemic Arterial HTN

  • Incidence - 29% -54%

  • Mechanism

    stage 1 - angiotensin II mediated

    stage 2 - impaired glycosylation

    stage 3 - nephropathy

  • Management - CCB, ACE inhibitors and

    Alpha adr blocking drugs


Cardiac autonomic neuropathy can

Cardiac autonomic neuropathy (CAN)

  • Degeneration of afferent and efferent nerve fibers of SNS&PSNS

  • Independent of age, duration of diabetes and severity of micro vascular complications

  • Impaired cardio vascular response to exercise and stress


Cardiac autonomic neuropathy can1

Cardiac autonomic neuropathy (CAN)

  • Increased cardiac morbidity

    Hemodynamic instability - impaired baroreflex

    Painless myocardial ischemia and infarction

    Dysrhythmias - VF

    Cardio respiratory arrest

    BJA 1993; 71: 258 – 261

    .Anesthesiology 1994; 80:326 –337

    .Anesth analg 1993;88:989 -991


Autonomic neuropathy

Autonomic neuropathy

  • 20% - 40% of diabetics

  • Influence anesthetic plan

  • Clinical predictors

    Prayer sign

    Peripheral neuropathy

  • History

    loss of sweating

    early satiety


Diabetic dysautonomic neuropathy scoring

Diabetic dysautonomic neuropathy scoring


Diabetic dysautonomic neuropathy scoring1

Diabetic dysautonomic neuropathy scoring


Temperature regulation visceral neuropathy

Temperature regulation & Visceral neuropathy

  • Risk of hypothermia - impaired vasoconstriction

    Anesthesiology 2000;92(5):1311 –8

  • Gastro paresis

    Due to vagal denervation

    Associated with esophageal dysmotility

    Reduced LES tone

    At risk of aspiration

    Anesth Analg 1994; 79: 943 – 47


Neurological risk

Neurological risk

  • Peripheral neuropathy

    • Mono –poly

    • 7.5% of type 2 DM

    • 10%-27%increase in mortality

    • Risk of nerve compression

    • Preferable to avoid neural blocks in pre existing

      neuropathies


Respiratory risk

Respiratory risk

  • Impaired function even at early stage

  • Higher plasma HbA1c level correlates significant Impairment

  • Decrease in the reactivity to cough and ventilatory response to hypoxia and hypercapnia

  • PFT – reduced TV, FEV and Impaired DLco

  • Loss of elastic properties and altered transport capacities


Difficult intubation risk

Difficult intubation risk

  • 33.2% of long standing type 1 DM

  • “Stiff joint syndrome” - Rigidity of atlanto occipital joint,

    tight waxy skin ,non familial short

    stature and joint rigidity

  • “Prayer sign” & “Palmer print sign”

  • Vagus & recurrent laryngeal nerve neuropathy

  • Difficult in laryngoscopy & intubation combined risk of aspiration

    Ref : Anesthesiology 1986; 64: 366 – 68

    Acta Anesth Scand 1998;42:199 -203


Renal risk

Renal risk

  • Risk of ARF

  • Major contributing factors

    • Hemodynamic instability

    • Decreased renal perfusion

    • Urosepsis

  • UTI - Most common post op complication

  • Renal failure - Most frequent major complication

    incidence 7%

  • Microalbiminuria - Predicts general severity of DM

    Not a marker of renal failure


  • Wound healing and infection

    Wound healing and infection

    • Long known phenomenon

    • Pre & post operative glycemic control restore healing

    • Continuous insulin infusion favors healing

    • Higher rate of wound infection


    Basic lab investigations

    Basic lab investigations

    • Fasting glucose

    • Electrolytes

    • BUN & creatinine

    • ECG


    Anesthetic agents and diabetes

    Anesthetic agentsand diabetes

    • Induction agents

      Etomidate : Blocks adrenal steroidogenesis

      BZD : Stimulate GH secretion

      Propofol : Reduced ability to clear lipids

    • Inhalation agents

      Inhibit insulin action on glucose

      Short lived


    Regional anesthesia vs ga

    Regional anesthesia vs GA

    • Epidural anesthesia blocks catecholamine release

    • Caution - LA dose & nerve injury

    • Inhibition of stress by opioid – limited to intraop period

    • No evidence to support RA over GA

    • Stable anesthesia - the goal

    • Quality of anesthesia

    • Schedule early in the day


    Out vs in patient surgery

    Out vs. In patient surgery

    Out patient if

    Evaluation of history in advance

    Prehydration

    Monitoring need

    No CNS ischemia

    Pregnancy

    Glucose monitoring

    Plan higher admit rate

    Look for red wound


    Insulin preparations and guidelines

    Insulin preparations and guidelines


    Insulin preparations and guidelines1

    Insulin preparations and guidelines


    Insulin preparations and guidelines2

    Insulin preparations and guidelines


    Insulin preparations and guidelines3

    Insulin preparations and guidelines


    Oral hypoglycemic agents

    Oral Hypoglycemic Agents


    Oral hypoglycemic agents1

    Oral Hypoglycemic Agents


    Oral hypoglycemic agents2

    Oral Hypoglycemic Agents

    [email protected]


  • Login