Diabetes mellitus – anaesthetic - PowerPoint Presentation

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Diabetes mellitus – anaesthetic management

Dr. S. Parthasarathy

MD., DA., DNB, MD (

Acu

), Dip.

Diab

. DCA,

Dip. Software statistics, PhD(physiology

)

IDRA FICA

Mahatma Gandhi Medical College and Research Institute,

Puducherry

, India

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Definition

Diabetes mellitus

is clinical syndrome resulting

from an inadequate supply of insulin and/or an inadequate tissue response to insulin, yielding increased circulating glucose levels with eventual microvascular and macrovascular complications.Classical poly – Genital itch, loss of weight, but appetite Mostly incidental finding

Dr SPS

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India is the diabetic capital The disease affects more than 62 million Indians, which is more than 7.1% of India's Adult Population

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Types 1. – immune mediated – beta cell failure

2

. 90 % no immune – beta cell dysfunction

MODY , Secondary ( drugs, thyroid etc) GDM Insulin dependent ?? ( type does not matter – insulin needed to prevent ketosis )Dr SPS

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Diagnosis Symptoms + RBS of 200 mg %

FBS of 126 + PPBS of 200 mg%

HbA1C of > 6.5

Prediabetes 100 – 125 – IFG 140 – 199 – IGT Dr SPS

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Which blood ? Arterial and capillary blood yield glucose values approximately 7% higher than venous blood.

Whole blood determinations are usually 15% lower than plasma or serum values.

Fasting or PP – capillary may vary

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Treatment Lifestyle modifications MNT Drugs

Insulin

Dr SPS

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Drugs Biguanides

:

Metformin

Glitazones - PPAR Gamma (peroxisomeproliferator-activated receptor-γ)Secretogogues – s.u. and non s.u.Agents reduce absorbtion of carbohydrate – acarbose (α-glucosidase inhibitors)Dr SPS

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Incretins and Drugs

Incretin

effect

Oral glucose or IV glucose to attain same blood sugar –oral – better insulin secretion Incretins GIP, GLP1- metabolized by DPP IV DPP 4 inhibitors (dipeptidyl peptidase IV)- gliptins Incretin analogues - Exenatide , liraglutide Dr SPS

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Others Colesevelum

Amylin

(pramlintide) pramlintide is started as a 60-μg SC injection before each meal and may be titrated up to amaximum of 120 μgBromocrytine Monoclonal antibody Insulin Dr SPS

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Mechanisms

Pictures from internet for closed academic purpose only

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Insulin Porcine insulin Human insulin Analogues

Short, long, mixtures

Biomedical and biotech !!

Only place -- Digital to analogues !!

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Insulins

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Think of

mixtard

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Insulin treatment types

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Complications

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Complications -Microvascular

Nephropathy

Approximately 30% to 40% of type 1 diabetics5% to 10% of type 2 diabetics develop end-stage renal disease

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Nephropathy

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Peripheral Neuropathy

More than 50% of patients who have had diabetes for more than 25 years will develop a peripheral neuropathy.

Glycemic

control is the only effective treatment.ANS

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Complications -Microvascular

Retinopathy

Visual impairment can range from minor changes in color vision to total blindness

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Macrovascular CAD

Dyslipidemia

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Anaesthetic

implications

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What do we do to diabetes ??Surgery and general anesthesia can result in a state of relative insulin

hyposecretion

and insulin resistance by release of hormones such as

glucocorticoids, growth hormone, catecholamines, and glucagonFood intake becomes ??

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Surgery and anesthesia!Acute hyperglycemia causes dehydration,

impaired wound healing,

increased rate of infection,

worsening central nervous system/spinal cord injury with ischemia, hyperviscosity with thrombogenesis.

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The essence of PAC Assessment of glycemic profile

Over a few days !

Assessment of end organ damageHistory and examination

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Preoperative check up Postpone elective surgery if possible if

glycaemic

control is poor

HbA1C ?? – usually needed for us to know the control – may not come down as an emergency – think of fitness on RBS !! RBS 300 mg % ??Cardiovascular disease – including an assessment of exercise tolerance;Silent ischemia or infarction- look

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Preoperative check up Drugs – also for

comorbid

conditions

Neuropathy – general + autonomic, and the drugs – document Nephropathy The “prayer sign,” an inability to approximate the palmar surfaces of the interphalangeal joints, is associated with stiff joint syndrome and may predict difficult laryngoscopy.

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Prayer sign

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Why are we particular about ANS??

Clues

Resting

tachy Orthostatic hypotension Nocturnal diarhoea

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ANS Diabetic patients with autonomic neuropathy are at increased risk for

intraoperative

hypotension and

perioperative cardiorespiratory arrest. exaggerated pressor response to tracheal intubation.Autonomic neuropathy predisposes to intraoperative hypothermia ( peripheral vasoconstriction ? ) Hypoglycemia unawareness

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ANS ?? Atropine – action ?

Beta blockers ??

autonomic dysfunction may involve

denervation of vagal control and cardiac accelerator control may demonstrate altered respiratory reflexes and impaired ventilatory responses to hypoxia and hypercapnia

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Firm, woody, nonpitting edema of the posterior neck and upper back (

scleredema

of diabetes) coupled with impaired joint mobility limits complete range of motion of the neck and may render

endotracheal intubation difficult.Gastroparesis and metoclopramide

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Hyperglycemia Dehydration Electrolyte abnormalities

Is there a nephropathy ?

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Major or minor surgery Food intake within 24 hours – minor

Cant resume food for 24 hours – major

Six hours !!

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The essence the nature of the diabetes and its treatment (insulin dependent or non-insulin-dependent)

the magnitude of the surgery contemplated,

duration of fasting

the time available for improving control of the diabetes preoperatively if necessary.

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Surgery and diabetes Stress response Catecholamines

, glucagon, interleukin 1 and corticotrophins

Hyperglycemic

Alpha action (inhibition of insulin release predominates peri op)

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Its catabolic But we want anabolic effects

First in the list

As an outpatient ??

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When to switch over to active insulin control ??

All type 1 diabetics

All type 2 diabetics- OHA is taken but poor control coming for surgery for major surgery

FBS > 190 or HbA1C > 9 % Well Controlled – major -- optional !! Decide on case to case basis

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Clinical facts

New hyperglycemia has 13 % more morbidity

Infection rate 2.7 times higher if RBS is>220 mg%

Hypotensive anaesthesia – RBS below 200 is a must Beware of ketosis Hypoglycemia is more common with tight control regimens Mortality three times more – uncontrolled diabetes for CABG

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Premedication and PAC Ranitidine and metoclopramide

Beta blockers – OK

Atorvastat – ok Aspirin and ACE – plan No anticholinergics Document neuropathies

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Investigations Hb ECG – rate , rhythm , chamber enlargement etc …. intervals !!

X Ray chest

Urinalysis

Total Count Creatinine Electrolytes If any doubt ECHO //// silent MI, DCM

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Anti diabetic drugs

Withhold all OHAs

all OHAs can be started as soon as patient takes oral diet

Chlopropamide is different – long acting – stopped a few days prior Metformin is exception -------?

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Contrast-induced nephropathy may result in lactic acidosis especially in patients taking

Metformin

.

• Serum creatinine should be checked before Metformin is restarted following intravenous radio-contrast administration. • The risk of lactic acidosis following intravenous contrast administration for patients with normal renal function is low.

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Glargine ??

If the patient uses

glargine

and lispro or aspart for daily glycemic control, the patient should take two thirds of the glargine dose and the entire lispro or aspart dose the night before surgery and hold all morning dosing.Then regimens

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Regimens – both understand ??

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No insulin , no glucose regimen

pre-existing

glycemic

control is good and minor surgery only is planned,Breakfast and oral agents are omitted on the morning of surgery (long-acting sulfonylureas should be omitted on the day prior to surgery). Dextrose infusions should be avoidedblood glucose checked every 2 hours.Start drugs as soon as possible Need not admit

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Stabilize on insulin Good control with major

Poor control with minor

Admit

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Control BGL the “basal-bolus” regimen• twice daily or thrice daily pre-mixed insulin,

• a combination of short-and intermediate-acting insulin in the morning and evening.

Some patients receiving insulin may also take oral AHG.

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Classic “Non–Tight Control” Regimen

Aim: To prevent hypoglycemia,

ketoacidosis

, and hyperosmolar states. 130 mg% approx 1.    NPO after midnight 2.    At 6 am on the day of surgery, 5% dextrose at a rate of 125 mL/hr/70 kg body weight.    3.    After starting the intravenous infusion, give half the usual morning insulin dose (and the usual type of insulin) subcutaneously.    4.    Continue 5% dextrose solutions through the operative period and give at least 125 mL/hr/70 kg body weight.    5.    In the recovery room, monitor blood glucose concentrations and treat on a sliding scale.

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Sliding scale !!?? Not much useful in poorly controlled diabetes Cant continue for days together

Glucose

Reg. Insulin (SC

or IV)

150- 200

2

201 – 250

4

251-300

6

301-350

8

> 350

10

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tight controltight control of blood glucose might be of benefit for pregnant diabetics (and their future offspring)

for diabetics undergoing cardiopulmonary bypass,

for those with (global) CNS ischemia

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Tight Control” Regimen 1

To keep plasma glucose levels at 80 to 120 mg/

dL

. improve wound healing and prevent wound infections, improve neurologic outcome after global or focal CNS ischemic insults, improve weaning from cardiopulmonary bypass.Not much bothered about hypo

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Tight control

On the evening before surgery, determine the

preprandial

blood glucose level.    2.    Through a plastic cannula, begin an intravenous infusion of 5% dextrose in water at a rate of 50 mL/hr/70 kg body weight.Piggy back 50 ml saline with insulin Check blood sugar 4th hourly Glucose / 150 or 100 – according to values and steroids and BMI

Intraop

– every hour check BGL

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Piggyback

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Tight Control- Regimen 2

Aim: Same as for Tight Control Regimen 1.

Protocol:   

1.    Obtain a “feedback mechanical pancreas” and set the controls for the desired plasma glucose regimen.    2.    Institute two appropriate intravenous lines.

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GIK regimen – alberti

An alternative regimen is the GKI (glucose–potassium–insulin) regimen whereby 15 units of soluble insulin with 10

mmol

of potassium chloride is added to a 500 ml bag of 10% dextrose and the mixture is infused over 5 hours.Switch over to SC insulin on diet

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“supplemental insulin regimen”. patient’s usual (or recently prescribed) insulin / oral AHG regimen, with provisions for supplemental

additional insulin if the BGL exceeds a certain threshold.

This supplemental insulin is always in the short- or rapid-acting form and given before meals and supper

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Afternoon list !!Give a reduced dose of insulin before early breakfast in the morning.

• Patients should arrive at the facility by 0900 AM and BGLs should be monitored closely in the pre-operative ward.

Same after

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Osmania general hospital regimen Vellore regimen

Krinsley

Protocol

Glucomander – software  Glucommander is a computerized algorithm that incorporates the blood glucose level, the current infusion rate, and the patient’s sensitivity to insulin to calculate any necessary change in insulin infusion rate

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Why should we need perioperative sugar control ??

Elevated glucose levels are also associated with renal injury, pulmonary complications, myocardial infarction,

cerebrovascular

insult, longer hospital and intensive care unit (ICU) stays, and increased mortality

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Some facts The incidence of difficult

laryngoscopy

in long-term type 1 diabetic patients is reported to be 30–40%.

1 unit of insulin lowers glucose approximately 25 to 30 mg/dLHypoglycemia does occur, treatment consists of administration of 50 mL of 50% dextrose in water, which typically increases the glucose level 100 mg/dL or 2 mg/dL/mL.

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Regional anaesthesia

Local anesthetic requirements are lower and the risk of nerve injury is higher in diabetic patients.

In addition, combining local anesthetics with epinephrine may pose an even greater risk for ischemic or edematous nerve injury (or both) in diabetics.

Hemodynamics in associated IHD ANS and hypotension

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BOWEL PREPARATION

•

The dose of insulin should be reduced during the period of bowel preparation.

• Short-acting insulin and oral AHG medication should be withheld. • Diet drinks are consumed if the BGL is elevated. • Patients with unstable diabetes should be admitted to hospital during the period of bowel preparation and an I-G infusion commenced.

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Anaesthetics

Etomidate

→

Ketamine →Propofol Benzodiazepines Opiates Halo, iso ,enflurane StableNo Not known Decrease cortisol but midaz – Abolish surgical catabolism Inhibit insulin secretion to glucose – invitro

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Emergency – rule out DKA Can delay by 4- 6 hours

An insulin bolus of 0.1 U/kg followed by an infusion of 0.1 U/kg per hour is the initial prescription.

Serum glucose is monitored hourly, and electrolytes are monitored every 2 hours. Potassium, magnesium, and phosphate deficits are replaced when urine production is documented.

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When serum glucose decreases to less than 250 mg/dL, intravenous fluids should include dextrose.

Insulin is continued until acidosis resolves.

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Postoperative

The net effects of the

neuroendocrine

response on metabolism during the convalescent stage after tissue injury include increased blood glucose, stimulation of lipolysis, and increased rate of gluconeogenesis

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Postoperative care HDU

Continue infusions till oral diet

To keep around 150 mg %

Change into preop schedule after dietTotal insulin requirement – 50 % long acting at bed time and the remaining 50 % in short acting two or three divided doses Four hourly checks Pain relief

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Scenarios

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Diabetes mellitus – RBS 198

Glimipride

+

metformin Hernioraphy Stop oral drugs on the day , monitor sugars Give diet post op and drugs

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DM on

mixtard

30/70 15 – 0 -12 SC

bd- RBS 194 Gastrojejunostomy 75 % dose the day prior with 5 % dextrose Tight regimen intra op

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DM on OHA –

gliptins

FBS – 100 PP 178

For CABG Switch over to insulin preop stabilize and start tight control

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DM with RBS of 350 on OHA for

TURP

Stabilze

on insulin preop May carry out with non tight regimens also

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DM with ANS involvement on OHA well controlled

Four hours plastic surgery of hand

Continue OHA and consider non tight

intraop or no insulin – no sugar

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Diabetic foot amputation 60 kg RBS 350 Wait for 4- 6hours

Inj. Insulin 6 units IV and 6 units / hour

Get below 250 . To correct metabolic abnormalities

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These are some guidesIndividual case decisions`

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If you are prepared ?

Thank you all