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Perioperative management of a
patient with Diabetes mellitus
R.Srihari
Topics for discussion
• WHO diagnostic criteria for Diabetes mellitus
• Implications of surgery in a diabetic
• Investigat...
WHO DIAGNOSTIC CRITERIA FOR
DIABETES MELLITUS
• Diabetes:
– Fasting plasma glucose >7mmol/l (126mg/dl)
– 2 hours plasma gl...
Implications of surgery in a diabetic
surgery
• The perioperative problems posed by surgery in
the diabetic patient:
– Str...
– Rise in blood sugar during surgery is related to
magnitude and inflammation:
• Excessive release of inflammatory cytokin...
– In fasting patients, undergoing elective intra-
abdominal procedures
Blood glucose levels typically increases to between...
– Interruption of oral intake, which may be further
prolonged after gastrointestinal surgery
lead to starvation
Predispose...
– Altered consciousness in perioperative period may
mask the symptoms and signs of hypoglycemia
– Circulatory disturbance ...
• Goals of perioperative diabetic management:
– Avoidance of hypoglycemia
– Avoidance of marked hyperglycemia
– Maintenanc...
• Preoperative Evaluation:
– Clinical Evaluation:
• Focus on cardiopulmonary risk assessment
• CAD more common in patients...
– Diabetes related:
• Determination of the type of diabetes :since type 1
Diabetes mellitus more at risk of DKA
• Long ter...
• Assessment of baseline glycemic control:
– Includes frequency of monitoring range of blood glucose
levels ; HbA1c
• Deta...
Investigations
• Hemoglobin:
– Anemia is present in patients with renal dysfunction
– Baseline investigation
– To guide bl...
• Serum creatinine:
– To detect renal dysfunction
• Fasting and Post-prandial blood sugars:
– To assess quality of control...
• S.Electrolytes:
– To detect abnormalities in patients with vomiting, diarrhoea,
poor oral intake or tube feeding, intest...
• Chest X-Ray:
– Tuberculosis is common in diabetics due to impaired
immmunity
– Patients with abdominal distension may ha...
• Glycemic targets:
Anesthetic Management
• Timing:
– Diabetic patients should be placed first on the
operating list
• This shortens their pre...
– Ideally 12 hour fast may be beneficial in diabetic
patient without surgery
– Some studies have shown beneficial effects ...
• Intravenous fluids:
– Ringers lactate:
• Lactate undergoes gluconeogenesis in the liver and may
complicate blood sugar c...
• Standard monitoring:
– ECG, NIBP, SpO2, EtCO2  MANDATORY
– Advanced monitoring may be needed depending on
the comorbidi...
– Glucose supplementation:
• Patients receiving long acting insulin are at risk of
hypoglycemia is glucose is not suplemen...
Anesthesia
• Induction:
– Choice of agent for general anesthesia depends on
severity of systemic illnesses
Epidural analge...
– Epidural analgesia may help to attenuate
neurohumoral stress response
+
To avoid systemic analgesics like NSAIDS and
opi...
– Careful induction with Etomidate/Fentanyl/Thiopentone should
be done
due to exaggerated hypotension due to autonomic neu...
• Maintenance of anesthesia:
– Isoflurane or Sevoflurane in air-oxygen mixture
– Nitrous oxide can be used but in patient...
– Airway pressure; if pressure after surgery with return
of airway reflexes can be extubated at the end of
surgery
• Effec...
– BZDs: dec ACTH release
 decreases cortisol when used in high doses
 decrease sympathetic response
but
stimulate growth...
– High dose opiates, anesthetic technique produces
hemodynamic, hormonal and metabolic stability
 They effectively block ...
– Ganglion blocking agents:
• May block sympathetically mediated hepatic
gluconeogenesis  with resultant hypoglycemia
– B...
Diabetic Emergencies
• Diabetic ketoacidosis
• Hyperosmolar hyperglycemic non-ketotic state
• Introduction:
– Diabetic ketoacidosis (DKA) and hyperosmolar
hyperglycemic state (HHS, also known as
hyperosmotic hyperg...
• Definitions:
– DKA:
• Metabolic acidosis is the major finding, while serum
glucose concentration is <800mg/dl. (~300-500...
• Pathophysiology:
Increased gluconeogenesis + hepatic and renal glucose
production
+
Impaired glucose utilization in peri...
• Precipitating Factors:
– The most common events:
• Infection (often pneumonia or urinary tract infection)
• Discontinuat...
• Other conditions and factors associated with DKA and
HHS include:
– Acute major illnesses such as myocardial infarction,...
• CLINICAL PRESENTATION:
– Diabetic ketoacidosis (DKA) usually evolves rapidly, over a 24-
hour period.
– In contrast, sym...
• Neurologic symptoms —
– Neurologic deterioration primarily occurs in patients with an
effective plasma osmolality above ...
• Abdominal pain in DKA —
– Patients with DKA may present with nausea, vomiting, and
abdominal pain; although more common ...
• Physical examination —
• Signs of volume depletion are common in both DKA
and HHS and include decreased skin turgor, dry...
• Diagnostic Evaluation:
• Both diabetic ketoacidosis (DKA) and hyperosmolar
hyperglycemic state (HHS) are medical emergen...
• The initial laboratory evaluation of a patient with suspected
DKA or HHS should include determination of:
– Serum glucos...
• Additional testing:
– cultures of urine, sputum, and blood, serum lipase
and amylase, and chest radiograph should be
per...
• Management:
– Intravenous fluids:
• Start with isotonic fluids at 1 litre/ hour (15-20ml/kg/hr)
• When blood glucose fal...
– Potassium:
• If initial serum Potassium < 3.3 mEq/L – hold insulin infusion
 give 40 mEq/l/hr till K >3.3 mEq/L
• If in...
– Phosphate:
• Supplementation indicated only in severe
hypophosphatemia
– Correction by administering 20-30 mEq/l with ea...
Perioperative management of a patient with diabetes mellitus
Perioperative management of a patient with diabetes mellitus
Perioperative management of a patient with diabetes mellitus
Perioperative management of a patient with diabetes mellitus
Perioperative management of a patient with diabetes mellitus
Perioperative management of a patient with diabetes mellitus
Perioperative management of a patient with diabetes mellitus
Perioperative management of a patient with diabetes mellitus
Perioperative management of a patient with diabetes mellitus
Perioperative management of a patient with diabetes mellitus
Perioperative management of a patient with diabetes mellitus
Perioperative management of a patient with diabetes mellitus
Perioperative management of a patient with diabetes mellitus
Perioperative management of a patient with diabetes mellitus
Perioperative management of a patient with diabetes mellitus
Perioperative management of a patient with diabetes mellitus
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Perioperative management of a patient with diabetes mellitus

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Anesthetic implications in a patient with Diabetes Mellitis with latest updates taken from british journal of anesthesia on perioperative glycemic control (2013)

Published in: Healthcare
  • this was very helpful, I would have loved to see the references on this presentation to develop our P&amp;P with EBM. But thank you. Nicely summarized.
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Perioperative management of a patient with diabetes mellitus

  1. 1. Perioperative management of a patient with Diabetes mellitus R.Srihari
  2. 2. Topics for discussion • WHO diagnostic criteria for Diabetes mellitus • Implications of surgery in a diabetic • Investigations • Principles of anesthetic management • Effects of anesthetic drugs on blood sugar • Hyperglycemic emergencies
  3. 3. WHO DIAGNOSTIC CRITERIA FOR DIABETES MELLITUS • Diabetes: – Fasting plasma glucose >7mmol/l (126mg/dl) – 2 hours plasma glucose > 11.1 mmol/l (200mg/dl) • Impaired Glucose Tolerance: – Fasting plasma glucose >7mmol/l (126mg/dl) – 2 hours plasma glucose : 7.8-11.1 mmol/l (140-200mg/dl) • Impaired Fasting Glucose: – Fasting plasma glucose 6.1-6.9(110-125mg/dl) – 2 hours plasma glucose <7.8 mmol/l (<140 mg/dl)
  4. 4. Implications of surgery in a diabetic surgery • The perioperative problems posed by surgery in the diabetic patient: – Stress response to surgery(magnitude depends on the site of surgery, tissue injury etc) • Secretion of catecholamines, cortisol and growth hormone oppose glucose homeostasis as these hormones have anti insulin and hyperglycemic effects Glycogenolysis and Gluconeogenesis are stimulated and peripheral glucose uptake is decreased causing hyperglycemia and ketosis
  5. 5. – Rise in blood sugar during surgery is related to magnitude and inflammation: • Excessive release of inflammatory cytokines such as Tumour Necrosis Factor, IL-1 and IL-6 and immobility Hyperglycemia
  6. 6. – In fasting patients, undergoing elective intra- abdominal procedures Blood glucose levels typically increases to between 126-180 mg/dl – During cardiac surgery  glucose values rise above 270mg/dl in subjects without Diabetes and above 360mg/dl – Stress may precipate Diabetic crisis
  7. 7. – Interruption of oral intake, which may be further prolonged after gastrointestinal surgery lead to starvation Predispose to ketosis Preoperative insulin administration is needed to control blood sugar Patient can be reverted to his/her presurgery diabetes management only after he resumes his normal oral intake
  8. 8. – Altered consciousness in perioperative period may mask the symptoms and signs of hypoglycemia – Circulatory disturbance associated with anesthesia and surgery may interfere with absorption of subcutaneous insulin  So it is ideal to administer iv insulin – Hyperglycemia is associated with increased risk of complications such as wound infection and poor neurological outcomes in susceptible
  9. 9. • Goals of perioperative diabetic management: – Avoidance of hypoglycemia – Avoidance of marked hyperglycemia – Maintenance of fluid/electrolyte balance – Prevention of ketoacidosis/hyperosmolar states – Return to stable glycemic control as soon as possible
  10. 10. • Preoperative Evaluation: – Clinical Evaluation: • Focus on cardiopulmonary risk assessment • CAD more common in patients with Diabetes – Hypertension – Obesity – Chronic Kidney Disease – Cerebrovascular Accident – Autonomic neuropathy
  11. 11. – Diabetes related: • Determination of the type of diabetes :since type 1 Diabetes mellitus more at risk of DKA • Long term complications of DM: – Retinopathy – Nephropathy – Neuropathy – Autonomic neuropathy – Coronary Artery Disease – Peripheral Vascular Disease – Hypertension
  12. 12. • Assessment of baseline glycemic control: – Includes frequency of monitoring range of blood glucose levels ; HbA1c • Detailed history of Diabetes therapy – Insulin type – Dose – Timing • Characteristics of surgery – Duration – Region
  13. 13. Investigations • Hemoglobin: – Anemia is present in patients with renal dysfunction – Baseline investigation – To guide blood transfusion intraoperatively • Total Leucocyte count: – To look for infection • Urine routine: – To look for microalbuminuria alerts presence of diabetic nephropathy
  14. 14. • Serum creatinine: – To detect renal dysfunction • Fasting and Post-prandial blood sugars: – To assess quality of control • Glycosylated Hb: – HbA1c <7% implies good control of blood sugar control over the preceding 8-12 weeks
  15. 15. • S.Electrolytes: – To detect abnormalities in patients with vomiting, diarrhoea, poor oral intake or tube feeding, intestinal obstruction – Also in patients on insulin therapy, ACEI, Diuretics and renal dysfunction  Potassium abnormal • ECG: – To detect asymptomatic myocardial ischemia • Echocardiography: – Should be done in patients with long standing diabetes and in patients with cardiovascular symptoms
  16. 16. • Chest X-Ray: – Tuberculosis is common in diabetics due to impaired immmunity – Patients with abdominal distension may have pneumonia secondary to basal atelectasis or aspiration • Morning of surgery investigations: – Serum electrolytes – Fasting Blood Sugar – Urine Ketones
  17. 17. • Glycemic targets:
  18. 18. Anesthetic Management • Timing: – Diabetic patients should be placed first on the operating list • This shortens their preoperative fast and risk of hypoglycemia and ketosis • Fasting: – Delayed gastric emptying due to diabetic autonomic neuropathy is found in up to 50% of patients with type 1 Diabetes Mellitus patiens Undiagnosed gastroparesis may prolonged retention of food in the stomach  Increased risk of regurgitation and aspiration
  19. 19. – Ideally 12 hour fast may be beneficial in diabetic patient without surgery – Some studies have shown beneficial effects of preoperative oral erythromycin on gastric motility
  20. 20. • Intravenous fluids: – Ringers lactate: • Lactate undergoes gluconeogenesis in the liver and may complicate blood sugar control when given in large volumes – Normal saline: • In large doses: Hyperchloremic acidosis – Hence both fluids need to used judiciously according to individual conditions – Dextrose solution
  21. 21. • Standard monitoring: – ECG, NIBP, SpO2, EtCO2  MANDATORY – Advanced monitoring may be needed depending on the comorbidities • Sugar control: – Permissive Hyperglycemia  is unacceptable in current practice with availabilty of more accurate, rapid and easy to use glucose  Postoperative wound healing and infection is influenced by adequacy of glycemic control
  22. 22. – Glucose supplementation: • Patients receiving long acting insulin are at risk of hypoglycemia is glucose is not suplemented • Perioperative administration of glucose enhances postoperative glucose utilization rates – Insulin supplementation: • Essential in patients with absolute insulin deficiency and infection  to prevent lipolysis and proteolysis with resultant ketosis  some of metabolic effects of suppression of insulin secretion are reversed by intraoperative insulin infusion
  23. 23. Anesthesia • Induction: – Choice of agent for general anesthesia depends on severity of systemic illnesses Epidural analgesia may be insituted after due consideration to autonomic neuropathy/ IHD/ Peripheral neuropathy MUST BE AVOIDED IN PATIENTS WITH SEPSIS
  24. 24. – Epidural analgesia may help to attenuate neurohumoral stress response + To avoid systemic analgesics like NSAIDS and opioids which may have serious side effects in the diabetics – A rapid sequence induction should be preferred technique for an anticipated difficult airway
  25. 25. – Careful induction with Etomidate/Fentanyl/Thiopentone should be done due to exaggerated hypotension due to autonomic neuropathy Succinyl choline should be avoided in patients with peripheral neuropathy due to risk of increased release of potassium Atracurium/Mivacurium may be used in case of renal dysfunction Rocuronium can be for rapid sequence induction
  26. 26. • Maintenance of anesthesia: – Isoflurane or Sevoflurane in air-oxygen mixture – Nitrous oxide can be used but in patients with intestinal obstruction should be avoided – Patients with perforated peritonitis should be ventilated postoperatively to increase oxygen delivery – Bowel distension and dense abdominal closure also makes postoperative ventilation desirable
  27. 27. – Airway pressure; if pressure after surgery with return of airway reflexes can be extubated at the end of surgery • Effects of anesthetic drugs on blood sugars: – Induction agents: • Ketamine: Significant hyperglycemia • Etomidate: Block adrenal steroidgenesis  dec cortisol – Inhalational agents: • In vitro studies shown to inhibit insulin response to glucose in reversible manner
  28. 28. – BZDs: dec ACTH release  decreases cortisol when used in high doses  decrease sympathetic response but stimulate growth hormone secretion result in decrease in glycemic response to Sx
  29. 29. – High dose opiates, anesthetic technique produces hemodynamic, hormonal and metabolic stability  They effectively block sympathetic nervous system and HPA axis  Probably by direct effect on hypothalamus HOWEVER, MIDAZOLAM AND FENTANYL MAY CAUSE HYPERGLYCEMIA BY REDUCING GLUCOSE CLEARANCE
  30. 30. – Ganglion blocking agents: • May block sympathetically mediated hepatic gluconeogenesis  with resultant hypoglycemia – Beta blockers are associated with slower recovery from hyperglycemia
  31. 31. Diabetic Emergencies • Diabetic ketoacidosis • Hyperosmolar hyperglycemic non-ketotic state
  32. 32. • Introduction: – Diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS, also known as hyperosmotic hyperglycemic nonketotic state [HHNK])  two of the most serious acute complications of diabetes – DKA is characterized by ketoacidosis and hyperglycemia, while HHS usually has more severe hyperglycemia but no ketoacidosis. – Each represents an extreme in the spectrum of hyperglycemia.
  33. 33. • Definitions: – DKA: • Metabolic acidosis is the major finding, while serum glucose concentration is <800mg/dl. (~300-500mg/dl) – HHS: • Little or no ketoacid accumulation, but glucose concentration exceeds 1000mg/dl + plasma osmolarity >380 mOsm/kg and neurological abnormalities - +++
  34. 34. • Pathophysiology: Increased gluconeogenesis + hepatic and renal glucose production + Impaired glucose utilization in peripheral tissues Hyperglycemia + Hyperosmolarity Increased counter regulatory hormones  lipolysis  free fatty acid oxidation  ketone bodies (Beta hydroxy butyrate, acetone, acetoacetate)
  35. 35. • Precipitating Factors: – The most common events: • Infection (often pneumonia or urinary tract infection) • Discontinuation of or inadequate insulin therapy. • Compromised water intake due to underlying medical conditions, particularly in older patients, can promote the development of severe dehydration and HHS
  36. 36. • Other conditions and factors associated with DKA and HHS include: – Acute major illnesses such as myocardial infarction, cerebrovascular accident, sepsis, or pancreatitis. – New onset type 1 diabetes, in which DKA is a common presentation. – Drugs that affect carbohydrate metabolism, including glucocorticoids, higher-dose thiazide diuretics, sympathomimetic agents (eg, dobutamine and terbutaline) and second-generation “atypical” antipsychotic agents – Cocaine use, which has been associated with recurrent DKA
  37. 37. • CLINICAL PRESENTATION: – Diabetic ketoacidosis (DKA) usually evolves rapidly, over a 24- hour period. – In contrast, symptoms of hyperosmolar hyperglycemic state (HHS) develop more insidiously with polyuria, polydipsia, and weight loss, often persisting for several days before hospital admission. • The earliest symptoms of marked hyperglycemia are polyuria, polydipsia, and weight loss. As the degree or duration of hyperglycemia progresses, neurologic symptoms, including lethargy, focal signs, and obtundation, can develop  This can progress to coma in later stages. Neurologic symptoms are most common in HHS, Hyperventilation and abdominal pain are primarily limited to patients with DKA.
  38. 38. • Neurologic symptoms — – Neurologic deterioration primarily occurs in patients with an effective plasma osmolality above 320 to 330 mosmol/kg – Mental obtundation and coma are more frequent in HHS than DKA because of the usually greater degree of hyperosmolality in HHS – In addition, some patients with HHS have focal neurologic signs (hemiparesis or hemianopsia) and/or seizures – Mental obtundation may occur in patients with DKA, who have lesser degrees of hyperosmolality, when severe acidosis exists – However, stupor or coma in diabetic patients with an effective plasma osmolality lower than 320mosmol/kg demands immediate consideration of other causes of the mental status change.
  39. 39. • Abdominal pain in DKA — – Patients with DKA may present with nausea, vomiting, and abdominal pain; although more common in children, these symptoms can be seen in adults – Abdominal pain is unusual in HHS – Abdominal pain was associated with the severity of the metabolic acidosis but did not correlate with the severity of hyperglycemia or dehydration. • Possible causes of abdominal pain include – delayed gastric emptying – ileus induced by the metabolic acidosis and associated electrolyte abnormalities – Other causes for abdominal pain, such as pancreatitis, should be sought when they occur in the absence of severe metabolic acidosis and when they persist after the resolution of ketoacidosis.
  40. 40. • Physical examination — • Signs of volume depletion are common in both DKA and HHS and include decreased skin turgor, dry axillae and oral mucosa, low jugular venous pressure, tachycardia, and, if severe, hypotension. • Patients with DKA may have a fruity odor (due to exhaled acetone; this is similar to the scent of nail polish remover) • deep respirations reflecting the compensatory hyperventilation (called Kussmaul respirations).
  41. 41. • Diagnostic Evaluation: • Both diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS) are medical emergencies that require prompt recognition and management – Initial evaluation — The initial evaluation of patients with hyperglycemic crises should include assessment of cardiorespiratory status, volume status, and mental status. – The initial history and rapid but careful physical examination should focus on: • Airway, breathing, and circulation (ABC) status • Mental status • Possible precipitating events (eg, source of infection, myocardial infarction) • Volume status
  42. 42. • The initial laboratory evaluation of a patient with suspected DKA or HHS should include determination of: – Serum glucose – Serum electrolytes (with calculation of the anion gap), blood urea nitrogen (BUN), and plasma creatinine – Complete blood count (CBC) with differential – Urinalysis and urine ketones by dipstick – Plasma osmolality – Serum ketones (if urine ketones are present) – Arterial blood gas if the serum bicarbonate is substantially reduced or hypoxia is suspected – Electrocardiogram
  43. 43. • Additional testing: – cultures of urine, sputum, and blood, serum lipase and amylase, and chest radiograph should be performed on a case-by-case basis – Measurement of glycosylated hemoglobin (A1C) may be useful in determining whether the acute episode is the culmination of an evolutionary process in previously undiagnosed or poorly controlled diabetes or a truly acute episode in an otherwise well- controlled patient
  44. 44. • Management: – Intravenous fluids: • Start with isotonic fluids at 1 litre/ hour (15-20ml/kg/hr) • When blood glucose falls to 250mg/dl  change to 5% Dextrose in 0.45%/0.9% normal saline at 150-200 ml/hr – Insulin: • Regular insulin: 0.15 units/kg as Intravenous bolus then infuse at 0.1units/kg/hour • Adjust infusion so that blood glucose decreases by 50-75 mg/dl • When glucose levels reach 250mg/dl, decrease infusion rate to 0.05-0.1 units/kg/hour  Maintain blood glucose at 150-200 mg/dl • Begin s/c insulin when DKA resolves (pH >7.3)
  45. 45. – Potassium: • If initial serum Potassium < 3.3 mEq/L – hold insulin infusion  give 40 mEq/l/hr till K >3.3 mEq/L • If initial serum potassium 3.3-4.9  give 20-30 mEq Potassium in each litre to keep S.K at 4-5 mEq/L • If initial Serum Potassium >5  do not give Potassium but check levels every 2 hourly – Bicarbonate: • Given only when severe metabolic acidosis is present pH<6.9 • Bicarb deficit: 0.6 x Wt(Kg) x (24- measured bicarbonate)
  46. 46. – Phosphate: • Supplementation indicated only in severe hypophosphatemia – Correction by administering 20-30 mEq/l with each litre of fluid

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