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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Presentation Transcript
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.

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

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

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