Diabetes mellitus anesthetic implications including perioperative glycemic control
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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

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Diabetes mellitus anesthetic implications including perioperative glycemic control

Diabetes Mellitus & Anesthetic Implications, Including Perioperative Glycemic Control

[email protected]


Outline
outline Perioperative Glycemic Control

  • Definition, diagnosis & classification

  • Pre op systematic evaluation

  • Over view of anesthetic techniques

  • Pharmacology of insulin &OHA

  • Peri op glycemic control


Definition who
Definition ( WHO) Perioperative Glycemic Control

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.




Preoperative evaluation risk assessment
Preoperative evaluation &risk assessment ADA)

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 ADA)

  • Major disturbances

    Coronary artery disease

    Arterial HTN

    Impaired LV function

    Cardiac dysautonomy

    Sudden death


Diabetic coronary artery disease
Diabetic coronary artery disease ADA)

  • 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 ADA)

  • 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) ADA)

  • 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 ADA))

  • 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 ADA)

  • 20% - 40% of diabetics

  • Influence anesthetic plan

  • Clinical predictors

    Prayer sign

    Peripheral neuropathy

  • History

    loss of sweating

    early satiety




Temperature regulation visceral neuropathy
Temperature regulation & Visceral neuropathy ADA)

  • 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 ADA)

  • 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 ADA)

  • 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 ADA)

  • 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 ADA)

  • 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 ADA)

    • 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 ADA)

    • Fasting glucose

    • Electrolytes

    • BUN & creatinine

    • ECG


    Anesthetic agents and diabetes
    Anesthetic agents ADA)and 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 ADA)

    • 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 ADA)

    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








    Oral hypoglycemic agents2
    Oral Hypoglycemic Agents ADA)

    [email protected]


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