This document provides guidance on the anaesthetic management of patients with diabetes mellitus, pheochromocytoma, or adrenal insufficiency undergoing surgery. For diabetes, it discusses preoperative assessment and glycemic control, including insulin infusion regimens. For pheochromocytoma, it emphasizes the importance of preoperative alpha-blockade to control blood pressure before surgery. For adrenal insufficiency, it notes the need for glucocorticoid and mineralocorticoid replacement in bilateral adrenalectomy. The document provides detailed recommendations for the perioperative care of patients with these endocrine conditions.
1. Myxedema coma is a life-threatening complication of severe untreated hypothyroidism, often precipitated by an acute illness. It involves altered mental status and multiple organ dysfunction.
2. Clinical features include symptoms of hypothyroidism along with hypothermia, hypotension, hypoventilation, coma and signs of precipitating illnesses. Investigations show features of hypothyroidism.
3. Treatment involves intensive care support including ventilatory support, cardiac monitoring and gradual rewarming. Thyroid hormone replacement is given cautiously along with treating any underlying illnesses.
The document provides guidelines for perioperative glycemic control in diabetic patients undergoing surgery. It discusses:
- The increasing prevalence of diabetes and importance of glycemic control around surgery.
- Evaluating diabetic patients preoperatively to optimize control and identify risks.
- Managing diabetes medications and blood sugars perioperatively depending on the surgery's scale, using insulin infusions or the patient's regular regimen.
- Monitoring blood sugars closely during and after surgery to maintain levels between 6-10 mmol/L to reduce surgical risks.
1) Type 1 diabetes (T1D) results from the autoimmune destruction of pancreatic beta cells, leading to insulin deficiency. It accounts for about 95% of diabetes cases in children.
2) Management of diabetic ketoacidosis (DKA) in T1D involves fluid resuscitation, continuous intravenous insulin infusion, monitoring of blood glucose and electrolytes, and treatment of the underlying precipitating cause.
3) Long-term management of T1D focuses on achieving optimal blood glucose control through multiple daily insulin injections or insulin pump therapy, along with carbohydrate counting and sick day rules. Close monitoring is needed to prevent complications.
This document discusses diabetes mellitus and its effects and management. It begins by describing how the pancreas normally secretes insulin and insulin's effects on the liver, muscle, and fat tissues. It then defines diabetes as a condition of high blood glucose levels and classifies the main types as type 1 (insulin-dependent) and type 2 (insulin-resistant). Complications of diabetes include acute issues like diabetic ketoacidosis and hypoglycemia as well as chronic microvascular and macrovascular damage. Proper management of diabetes and blood glucose levels during surgery is also discussed.
Diabetic ketoacidosis (DKA) is a life-threatening complication of diabetes mellitus caused by a lack of insulin. It is characterized by hyperglycemia, acidosis, and ketosis. The key precipitating factor is severe insulin deficiency. Diagnosis is based on hyperglycemia, presence of ketones, acidosis, and other metabolic disturbances. Treatment involves fluid resuscitation, insulin therapy to lower blood glucose levels, electrolyte replacement, and treating any underlying infections. Careful monitoring is needed to gradually correct metabolic abnormalities and avoid complications like cerebral edema.
The document discusses the anaesthetic management of diabetes mellitus, including the types and diagnosis of diabetes, physiology of insulin, perioperative response to surgery and anesthesia, complications, and considerations for management related to cardiovascular disease, renal dysfunction, neuropathies, and different types of surgery. It provides guidance on pre-operative, intra-operative, and post-operative glucose monitoring and management through intravenous fluids, insulin administration, and glycemic control targets. Surgical procedures for both insulin-dependent and non-insulin dependent diabetes are outlined.
Perioperative Management of Diabetic Patient.pptxTushar Mankar
The document discusses the perioperative management of diabetic patients undergoing surgery. It covers:
1) The effects of surgery and anesthesia on blood sugar levels in diabetic patients, including increased stress hormones causing hyperglycemia and hypoglycemia risks.
2) Preoperative evaluation of diabetic patients including assessing glucose control, complications, organ function and optimizing medical status.
3) Different insulin regimens for maintaining intraoperative glycemic control like Alberti & Thomas, Modified Alberti and Osmania General Hospital protocols.
4) Postoperative management focusing on monitoring blood sugar levels and adjusting insulin doses accordingly.
DIABETES MELLITUS AND ANAESTHETIC IMPLICATIONS.pptxrijjorajoo
The document discusses diabetes mellitus and its implications for anesthesia, covering the different types of diabetes, diagnostic criteria, pathophysiology, complications, treatment regimens, and recommendations for perioperative management including maintaining normoglycemia, monitoring blood glucose levels intraoperatively, and using intravenous insulin infusions for patients fasting for longer periods. Special considerations are given to risks of hypoglycemia, infections, and other complications in diabetic surgery patients.
1. Myxedema coma is a life-threatening complication of severe untreated hypothyroidism, often precipitated by an acute illness. It involves altered mental status and multiple organ dysfunction.
2. Clinical features include symptoms of hypothyroidism along with hypothermia, hypotension, hypoventilation, coma and signs of precipitating illnesses. Investigations show features of hypothyroidism.
3. Treatment involves intensive care support including ventilatory support, cardiac monitoring and gradual rewarming. Thyroid hormone replacement is given cautiously along with treating any underlying illnesses.
The document provides guidelines for perioperative glycemic control in diabetic patients undergoing surgery. It discusses:
- The increasing prevalence of diabetes and importance of glycemic control around surgery.
- Evaluating diabetic patients preoperatively to optimize control and identify risks.
- Managing diabetes medications and blood sugars perioperatively depending on the surgery's scale, using insulin infusions or the patient's regular regimen.
- Monitoring blood sugars closely during and after surgery to maintain levels between 6-10 mmol/L to reduce surgical risks.
1) Type 1 diabetes (T1D) results from the autoimmune destruction of pancreatic beta cells, leading to insulin deficiency. It accounts for about 95% of diabetes cases in children.
2) Management of diabetic ketoacidosis (DKA) in T1D involves fluid resuscitation, continuous intravenous insulin infusion, monitoring of blood glucose and electrolytes, and treatment of the underlying precipitating cause.
3) Long-term management of T1D focuses on achieving optimal blood glucose control through multiple daily insulin injections or insulin pump therapy, along with carbohydrate counting and sick day rules. Close monitoring is needed to prevent complications.
This document discusses diabetes mellitus and its effects and management. It begins by describing how the pancreas normally secretes insulin and insulin's effects on the liver, muscle, and fat tissues. It then defines diabetes as a condition of high blood glucose levels and classifies the main types as type 1 (insulin-dependent) and type 2 (insulin-resistant). Complications of diabetes include acute issues like diabetic ketoacidosis and hypoglycemia as well as chronic microvascular and macrovascular damage. Proper management of diabetes and blood glucose levels during surgery is also discussed.
Diabetic ketoacidosis (DKA) is a life-threatening complication of diabetes mellitus caused by a lack of insulin. It is characterized by hyperglycemia, acidosis, and ketosis. The key precipitating factor is severe insulin deficiency. Diagnosis is based on hyperglycemia, presence of ketones, acidosis, and other metabolic disturbances. Treatment involves fluid resuscitation, insulin therapy to lower blood glucose levels, electrolyte replacement, and treating any underlying infections. Careful monitoring is needed to gradually correct metabolic abnormalities and avoid complications like cerebral edema.
The document discusses the anaesthetic management of diabetes mellitus, including the types and diagnosis of diabetes, physiology of insulin, perioperative response to surgery and anesthesia, complications, and considerations for management related to cardiovascular disease, renal dysfunction, neuropathies, and different types of surgery. It provides guidance on pre-operative, intra-operative, and post-operative glucose monitoring and management through intravenous fluids, insulin administration, and glycemic control targets. Surgical procedures for both insulin-dependent and non-insulin dependent diabetes are outlined.
Perioperative Management of Diabetic Patient.pptxTushar Mankar
The document discusses the perioperative management of diabetic patients undergoing surgery. It covers:
1) The effects of surgery and anesthesia on blood sugar levels in diabetic patients, including increased stress hormones causing hyperglycemia and hypoglycemia risks.
2) Preoperative evaluation of diabetic patients including assessing glucose control, complications, organ function and optimizing medical status.
3) Different insulin regimens for maintaining intraoperative glycemic control like Alberti & Thomas, Modified Alberti and Osmania General Hospital protocols.
4) Postoperative management focusing on monitoring blood sugar levels and adjusting insulin doses accordingly.
DIABETES MELLITUS AND ANAESTHETIC IMPLICATIONS.pptxrijjorajoo
The document discusses diabetes mellitus and its implications for anesthesia, covering the different types of diabetes, diagnostic criteria, pathophysiology, complications, treatment regimens, and recommendations for perioperative management including maintaining normoglycemia, monitoring blood glucose levels intraoperatively, and using intravenous insulin infusions for patients fasting for longer periods. Special considerations are given to risks of hypoglycemia, infections, and other complications in diabetic surgery patients.
ICU protocol for pre-eclampsia/ eclampsiamarwa Mahrous
This document provides guidance on the management of respiratory distress and hemodynamic instability in pregnant patients. It outlines the following steps: initial assessment and resuscitation, taking history and physical exam, sending investigations, making a differential diagnosis, admitting the patient to the ICU for close monitoring, managing severe preeclampsia, watching for complications, and managing complications. Specific guidance is provided on airway management, fluid resuscitation, seizure control with magnesium, blood pressure control, fluid management, indications for delivery, and management of HELLP syndrome and acute pulmonary edema.
DIABETES MELLITUS- Preop, Intraoperative management and considerationsZIKRULLAH MALLICK
The document discusses the metabolic effects of anesthesia and surgery in diabetic patients, which can include increased insulin resistance, hyperglycemia, and ketosis. It provides guidance on pre-operative evaluation and management of diabetic patients, including glycemic control targets and insulin adjustment. The goals of perioperative management are to maintain glycemic control, prevent complications, and minimize the metabolic consequences of starvation and surgical stress.
The child ingested 15 iron tablets containing a total of 975 mg of elemental iron, which is a potentially lethal dose. Diagnostic workup included an abdominal x-ray showing tablets in the stomach and intestine, and serum iron level. Whole bowel irrigation with polyethylene glycol was used for decontamination. The chelating agent desferoxamine was administered at 15 mg/kg/hr due to the large iron ingestion and presence of symptoms. Parameters like anion gap metabolic acidosis, leukocytosis, and hyperglycemia indicate severity. The prognosis depends on the ingested dose, time to treatment, and presence of complications.
Academic discussion/ Lecture class for 5th year MBBS students on Diabetic Emergencies, types, their sign-symptoms and managements. Most of the Data was taken from Davidson's Principles and Practice of Medicine.
This is a brief discussion on diabetes mellitus as medical emergency that can be encountered in any dental office.
What to do in such conditions is what I've briefly tried to explain over here.
Regards,
Dr. Abhishek Sharma
(M.D.S - 2016 Batch ; Oral & Maxillofacial Surgery)
This document provides a summary of diabetes mellitus (DM), including its definition, presentation, classifications, complications, investigations, and management. DM results from lack of or diminished insulin effectiveness and is characterized by hyperglycemia. There are two main types: type 1 DM is insulin-dependent while type 2 DM is non-insulin dependent initially but may eventually require insulin. Complications can include infections, neuropathy, retinopathy, and vascular diseases. Management involves lifestyle changes like diet and exercise as well as medications and insulin to manage blood glucose levels and prevent complications.
This document provides guidance on perioperative management of diabetic patients undergoing anesthesia. It outlines key factors to assess including type and control of diabetes, presence of complications, and nature of surgery. For preoperative evaluation, it recommends optimizing glycemic control, continuing most diabetic medications, and monitoring blood glucose closely. It also details management strategies for minor versus major surgery, including use of insulin infusions for tight glycemic control in major cases. Postoperatively, it emphasizes continued monitoring and gradual resumption of normal diabetic management. The goal is to avoid both hypoglycemia and hyperglycemia while minimizing surgical stress.
The document discusses various endocrine emergencies including hypoglycemia, diabetic ketoacidosis, hyperosmolar hyperglycemic state, syndrome of inappropriate antidiuretic hormone secretion, myxedema, thyroid storm, and adrenocortical insufficiency. It covers the definitions, etiologies, pathophysiology, clinical manifestations, diagnostic evaluations, and management of each condition. Nursing responsibilities in assessment and treatment are also outlined.
ANAESTHESIA FOR PATIENTS WITH RENAL FAILURE.pptxSweetPotatoe1
The document discusses renal failure and its implications for anesthesia. It describes the functions of the kidneys and defines acute kidney injury and chronic kidney disease. For patients with renal impairment, pre-operative optimization is important, including fluid management and electrolyte correction. Regional anesthesia is preferred over general anesthesia when possible due to better hemodynamic stability. Careful monitoring is needed during and after surgery to watch for fluid overload, electrolyte abnormalities, and other complications.
Hepatic Considerations In Oral Surgery .pptxSudiptaBera9
This document provides an overview of considerations for oral surgery in patients with liver disease. It discusses the functional role of the liver and risks associated with dental care for patients with liver disease such as impaired hemostasis, drug interactions, and increased susceptibility to infection. It also covers preoperative evaluation including liver function tests and coagulation assessment. Guidelines are provided for preoperative management including vitamin K replacement, drug dosing adjustments based on liver function, and anesthesia considerations. Postoperative management focuses on hemostasis and infection control.
Three key points about managing diabetes in surgical patients:
1. Surgery causes stress responses that can worsen blood sugar control and increase insulin resistance. Tight control is important to reduce complications.
2. The document provides guidelines for managing diabetes in both major and minor surgeries, including adjusting insulin doses pre-operatively and monitoring blood sugar closely during and after surgery.
3. For major surgeries, an insulin-glucose infusion is recommended starting before surgery and continuing for at least 24 hours post-operatively to maintain tight control and prevent hyperglycemia from worsening outcomes.
The document discusses the perioperative management of diabetes mellitus. It provides criteria for diagnosing diabetes, discusses how surgery and diabetes affect metabolism, and outlines recommendations for preoperative evaluation and glycemic control in the perioperative period. The goals are to maintain good glycemic control, prevent complications, and shift patients back to their usual diabetes medications and diet as quickly as possible after surgery.
This document discusses chronic kidney disease (CKD), including its causes, symptoms, complications, diagnostic tests, management, and treatment options. It notes that CKD refers to irreversible deterioration of renal function over years and is asymptomatic until the glomerular filtration rate falls below 30 mL/min/1.73 m2. Common symptoms when it falls below 15-20 mL/min/1.73 m2 include tiredness, breathlessness, pruritus, and in advanced cases, Kussmaul breathing and coma. The aims of management are to monitor renal function, prevent further damage, limit complications, treat risk factors, and prepare for renal replacement therapy. Treatment involves controlling blood pressure and proteinuria, managing
Parenteral nutrition (PN) can result in numerous complications if not carefully monitored. Mechanical complications include injuries from catheters. Metabolic complications involve issues like hyperglycemia, hepatic dysfunction, and refeeding syndrome. Infections from catheters are also common. Close monitoring of patients on PN is necessary to check for metabolic and clinical issues and manage complications. Careful attention to nutrient levels and other medical factors can help reduce risks.
Anaesthetic Management of Diabetes Mellitus in Pediatricscairo1957
This document discusses the anesthetic management of pediatric diabetes mellitus. The key goals are providing balanced glycemic control to avoid hypoglycemia and hyperglycemia. Various insulin regimens and preparations are outlined. Preoperative assessment focuses on blood glucose, metabolic control, and electrolyte balance. Intraoperatively, blood glucose is closely monitored and IV insulin may be used. Postoperatively, the child's usual insulin or oral medication regimen is restarted once oral intake resumes. Hypoglycemia is avoided through careful glucose monitoring during all phases of care.
A review of the investigation and management of diabetic ketoacidosis in newly diagnosed type I diabetes. Patient details have been changed and anonymised to protect the identity of the individual.
DIABETIC KETOACIDOSIS PRESENTATION BY ROOMA KHALIDRooma Khalid
This document discusses diabetic ketoacidosis (DKA). It defines DKA and its signs and symptoms. DKA occurs more often in type 1 diabetes and is characterized by blood glucose over 250 mg/dl, blood pH below 7.3, and ketones in serum over 5 mEq/L. Proper treatment of DKA involves fluid replacement, insulin administration, and monitoring of blood glucose, electrolytes, and pH to correct dehydration, hyperglycemia, and acidosis. Failure to treat the patient's DKA led to worsening of her condition.
This document provides information on diabetic emergencies including diabetic ketoacidosis (DKA), hyperglycemic hyperosmolar state (HHS), and hypoglycemia. It defines each condition, describes their pathogenesis and precipitating factors, outlines their clinical features and diagnostic criteria, and provides guidance on management and treatment. DKA is characterized by hyperglycemia, metabolic acidosis, and high ketone levels, while HHS involves severe hyperglycemia, hyperosmolality, and minimal ketosis. Hypoglycemia is defined as a blood glucose level below 3.9 mmol/L. The document emphasizes the need for prompt treatment of these diabetic emergencies.
1. Paracetamol (acetaminophen) toxicity results from formation of a reactive metabolite which causes liver and occasionally renal failure. Acetylcysteine treatment within 8 hours of overdose is highly effective at replenishing glutathione reserves and preventing toxicity.
2. Salicylate poisoning causes respiratory alkalosis, metabolic acidosis, and organ dysfunction. Treatment involves correcting dehydration and acidosis with sodium bicarbonate, and hemodialysis for severe or refractory cases.
3. Tricyclic antidepressant overdose can cause life-threatening arrhythmias, hypotension, and seizures due to sodium channel blockade and anticholinergic effects. Treatment involves
Test bank for karp s cell and molecular biology 9th edition by gerald karp.pdfrightmanforbloodline
Test bank for karp s cell and molecular biology 9th edition by gerald karp.pdf
Test bank for karp s cell and molecular biology 9th edition by gerald karp.pdf
Test bank for karp s cell and molecular biology 9th edition by gerald karp.pdf
ICU protocol for pre-eclampsia/ eclampsiamarwa Mahrous
This document provides guidance on the management of respiratory distress and hemodynamic instability in pregnant patients. It outlines the following steps: initial assessment and resuscitation, taking history and physical exam, sending investigations, making a differential diagnosis, admitting the patient to the ICU for close monitoring, managing severe preeclampsia, watching for complications, and managing complications. Specific guidance is provided on airway management, fluid resuscitation, seizure control with magnesium, blood pressure control, fluid management, indications for delivery, and management of HELLP syndrome and acute pulmonary edema.
DIABETES MELLITUS- Preop, Intraoperative management and considerationsZIKRULLAH MALLICK
The document discusses the metabolic effects of anesthesia and surgery in diabetic patients, which can include increased insulin resistance, hyperglycemia, and ketosis. It provides guidance on pre-operative evaluation and management of diabetic patients, including glycemic control targets and insulin adjustment. The goals of perioperative management are to maintain glycemic control, prevent complications, and minimize the metabolic consequences of starvation and surgical stress.
The child ingested 15 iron tablets containing a total of 975 mg of elemental iron, which is a potentially lethal dose. Diagnostic workup included an abdominal x-ray showing tablets in the stomach and intestine, and serum iron level. Whole bowel irrigation with polyethylene glycol was used for decontamination. The chelating agent desferoxamine was administered at 15 mg/kg/hr due to the large iron ingestion and presence of symptoms. Parameters like anion gap metabolic acidosis, leukocytosis, and hyperglycemia indicate severity. The prognosis depends on the ingested dose, time to treatment, and presence of complications.
Academic discussion/ Lecture class for 5th year MBBS students on Diabetic Emergencies, types, their sign-symptoms and managements. Most of the Data was taken from Davidson's Principles and Practice of Medicine.
This is a brief discussion on diabetes mellitus as medical emergency that can be encountered in any dental office.
What to do in such conditions is what I've briefly tried to explain over here.
Regards,
Dr. Abhishek Sharma
(M.D.S - 2016 Batch ; Oral & Maxillofacial Surgery)
This document provides a summary of diabetes mellitus (DM), including its definition, presentation, classifications, complications, investigations, and management. DM results from lack of or diminished insulin effectiveness and is characterized by hyperglycemia. There are two main types: type 1 DM is insulin-dependent while type 2 DM is non-insulin dependent initially but may eventually require insulin. Complications can include infections, neuropathy, retinopathy, and vascular diseases. Management involves lifestyle changes like diet and exercise as well as medications and insulin to manage blood glucose levels and prevent complications.
This document provides guidance on perioperative management of diabetic patients undergoing anesthesia. It outlines key factors to assess including type and control of diabetes, presence of complications, and nature of surgery. For preoperative evaluation, it recommends optimizing glycemic control, continuing most diabetic medications, and monitoring blood glucose closely. It also details management strategies for minor versus major surgery, including use of insulin infusions for tight glycemic control in major cases. Postoperatively, it emphasizes continued monitoring and gradual resumption of normal diabetic management. The goal is to avoid both hypoglycemia and hyperglycemia while minimizing surgical stress.
The document discusses various endocrine emergencies including hypoglycemia, diabetic ketoacidosis, hyperosmolar hyperglycemic state, syndrome of inappropriate antidiuretic hormone secretion, myxedema, thyroid storm, and adrenocortical insufficiency. It covers the definitions, etiologies, pathophysiology, clinical manifestations, diagnostic evaluations, and management of each condition. Nursing responsibilities in assessment and treatment are also outlined.
ANAESTHESIA FOR PATIENTS WITH RENAL FAILURE.pptxSweetPotatoe1
The document discusses renal failure and its implications for anesthesia. It describes the functions of the kidneys and defines acute kidney injury and chronic kidney disease. For patients with renal impairment, pre-operative optimization is important, including fluid management and electrolyte correction. Regional anesthesia is preferred over general anesthesia when possible due to better hemodynamic stability. Careful monitoring is needed during and after surgery to watch for fluid overload, electrolyte abnormalities, and other complications.
Hepatic Considerations In Oral Surgery .pptxSudiptaBera9
This document provides an overview of considerations for oral surgery in patients with liver disease. It discusses the functional role of the liver and risks associated with dental care for patients with liver disease such as impaired hemostasis, drug interactions, and increased susceptibility to infection. It also covers preoperative evaluation including liver function tests and coagulation assessment. Guidelines are provided for preoperative management including vitamin K replacement, drug dosing adjustments based on liver function, and anesthesia considerations. Postoperative management focuses on hemostasis and infection control.
Three key points about managing diabetes in surgical patients:
1. Surgery causes stress responses that can worsen blood sugar control and increase insulin resistance. Tight control is important to reduce complications.
2. The document provides guidelines for managing diabetes in both major and minor surgeries, including adjusting insulin doses pre-operatively and monitoring blood sugar closely during and after surgery.
3. For major surgeries, an insulin-glucose infusion is recommended starting before surgery and continuing for at least 24 hours post-operatively to maintain tight control and prevent hyperglycemia from worsening outcomes.
The document discusses the perioperative management of diabetes mellitus. It provides criteria for diagnosing diabetes, discusses how surgery and diabetes affect metabolism, and outlines recommendations for preoperative evaluation and glycemic control in the perioperative period. The goals are to maintain good glycemic control, prevent complications, and shift patients back to their usual diabetes medications and diet as quickly as possible after surgery.
This document discusses chronic kidney disease (CKD), including its causes, symptoms, complications, diagnostic tests, management, and treatment options. It notes that CKD refers to irreversible deterioration of renal function over years and is asymptomatic until the glomerular filtration rate falls below 30 mL/min/1.73 m2. Common symptoms when it falls below 15-20 mL/min/1.73 m2 include tiredness, breathlessness, pruritus, and in advanced cases, Kussmaul breathing and coma. The aims of management are to monitor renal function, prevent further damage, limit complications, treat risk factors, and prepare for renal replacement therapy. Treatment involves controlling blood pressure and proteinuria, managing
Parenteral nutrition (PN) can result in numerous complications if not carefully monitored. Mechanical complications include injuries from catheters. Metabolic complications involve issues like hyperglycemia, hepatic dysfunction, and refeeding syndrome. Infections from catheters are also common. Close monitoring of patients on PN is necessary to check for metabolic and clinical issues and manage complications. Careful attention to nutrient levels and other medical factors can help reduce risks.
Anaesthetic Management of Diabetes Mellitus in Pediatricscairo1957
This document discusses the anesthetic management of pediatric diabetes mellitus. The key goals are providing balanced glycemic control to avoid hypoglycemia and hyperglycemia. Various insulin regimens and preparations are outlined. Preoperative assessment focuses on blood glucose, metabolic control, and electrolyte balance. Intraoperatively, blood glucose is closely monitored and IV insulin may be used. Postoperatively, the child's usual insulin or oral medication regimen is restarted once oral intake resumes. Hypoglycemia is avoided through careful glucose monitoring during all phases of care.
A review of the investigation and management of diabetic ketoacidosis in newly diagnosed type I diabetes. Patient details have been changed and anonymised to protect the identity of the individual.
DIABETIC KETOACIDOSIS PRESENTATION BY ROOMA KHALIDRooma Khalid
This document discusses diabetic ketoacidosis (DKA). It defines DKA and its signs and symptoms. DKA occurs more often in type 1 diabetes and is characterized by blood glucose over 250 mg/dl, blood pH below 7.3, and ketones in serum over 5 mEq/L. Proper treatment of DKA involves fluid replacement, insulin administration, and monitoring of blood glucose, electrolytes, and pH to correct dehydration, hyperglycemia, and acidosis. Failure to treat the patient's DKA led to worsening of her condition.
This document provides information on diabetic emergencies including diabetic ketoacidosis (DKA), hyperglycemic hyperosmolar state (HHS), and hypoglycemia. It defines each condition, describes their pathogenesis and precipitating factors, outlines their clinical features and diagnostic criteria, and provides guidance on management and treatment. DKA is characterized by hyperglycemia, metabolic acidosis, and high ketone levels, while HHS involves severe hyperglycemia, hyperosmolality, and minimal ketosis. Hypoglycemia is defined as a blood glucose level below 3.9 mmol/L. The document emphasizes the need for prompt treatment of these diabetic emergencies.
1. Paracetamol (acetaminophen) toxicity results from formation of a reactive metabolite which causes liver and occasionally renal failure. Acetylcysteine treatment within 8 hours of overdose is highly effective at replenishing glutathione reserves and preventing toxicity.
2. Salicylate poisoning causes respiratory alkalosis, metabolic acidosis, and organ dysfunction. Treatment involves correcting dehydration and acidosis with sodium bicarbonate, and hemodialysis for severe or refractory cases.
3. Tricyclic antidepressant overdose can cause life-threatening arrhythmias, hypotension, and seizures due to sodium channel blockade and anticholinergic effects. Treatment involves
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Breast cancer: Post menopausal endocrine therapyDr. Sumit KUMAR
Breast cancer in postmenopausal women with hormone receptor-positive (HR+) status is a common and complex condition that necessitates a multifaceted approach to management. HR+ breast cancer means that the cancer cells grow in response to hormones such as estrogen and progesterone. This subtype is prevalent among postmenopausal women and typically exhibits a more indolent course compared to other forms of breast cancer, which allows for a variety of treatment options.
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The diagnosis of HR+ breast cancer begins with clinical evaluation, imaging, and biopsy. Imaging modalities such as mammography, ultrasound, and MRI help in assessing the extent of the disease. Histopathological examination and immunohistochemical staining of the biopsy sample confirm the diagnosis and hormone receptor status by identifying the presence of estrogen receptors (ER) and progesterone receptors (PR) on the tumor cells.
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Selective Estrogen Receptor Modulators (SERMs): Tamoxifen is a SERM that binds to estrogen receptors, blocking estrogen from stimulating breast cancer cells. It is effective but may have side effects such as increased risk of endometrial cancer and thromboembolic events.
Aromatase Inhibitors (AIs): These drugs, including anastrozole, letrozole, and exemestane, lower estrogen levels by inhibiting the aromatase enzyme, which converts androgens to estrogen in peripheral tissues. AIs are generally preferred in postmenopausal women due to their efficacy and safety profile compared to tamoxifen.
Selective Estrogen Receptor Downregulators (SERDs): Fulvestrant is a SERD that degrades estrogen receptors and is used in cases where resistance to other endocrine therapies develops.
Combination Therapies
Combining endocrine therapy with other treatments enhances efficacy. Examples include:
Endocrine Therapy with CDK4/6 Inhibitors: Palbociclib, ribociclib, and abemaciclib are CDK4/6 inhibitors that, when combined with endocrine therapy, significantly improve progression-free survival in advanced HR+ breast cancer.
Endocrine Therapy with mTOR Inhibitors: Everolimus, an mTOR inhibitor, can be added to endocrine therapy for patients who have developed resistance to aromatase inhibitors.
Chemotherapy
Chemotherapy is generally reserved for patients with high-risk features, such as large tumor size, high-grade histology, or extensive lymph node involvement. Regimens often include anthracyclines and taxanes.
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Histololgy of Female Reproductive System.pptxAyeshaZaid1
Dive into an in-depth exploration of the histological structure of female reproductive system with this comprehensive lecture. Presented by Dr. Ayesha Irfan, Assistant Professor of Anatomy, this presentation covers the Gross anatomy and functional histology of the female reproductive organs. Ideal for students, educators, and anyone interested in medical science, this lecture provides clear explanations, detailed diagrams, and valuable insights into female reproductive system. Enhance your knowledge and understanding of this essential aspect of human biology.
1. Dr. Huda Nasser
Course : 6
Year : 2008
Language : English
Country : Syria
City : Lattaquie
Weight : 789 kb
Related text : no
http://www.feea.net
ANAESTHESIA FOR
ENDOCRINE DISEASE
Associate Prof
Faculty of medicine - Aleppo university
2. Introduction
This lecture will focus on the management
of patients with diabetes mellitus,
pheochromocytoma and adrenal
insufficiency .
3. Diabetes Mellitus
• Adult normally secrete approximately 50
units of insulin each day from the B cells of
islets of Langerhans in the pancreas.
• Insulin consider as the most important
anabolic hormone , its lack is associated
with catabolism and a negative nitrogen
balance
4. Clinical manifestations
DM is characterized by impairment of
carbohydrate metabolism caused by
deficiency of insulin activity , which lead to
hyperglycemia and glycosuria .
The diagnosis is based on plasma glucose
>140 mg/dl or blood glucose >126mg/dl.
Glucose tolerance test >200 mg/dl
5. D M is classified to :
• Type I absolute insulin deficiency
secondary to immune –mediated or
idiopathic.
• Type II adult onset secondary to
resistance /relative deficiency.
• Type III specific types of D M secondary to
genetic defect .
• Type IV Gestational.
6. Anaesthetic Management :
1- Preoperative Assessment
Diabetes causes diseases in many organ
systems, the severity of which may be
related to how long the disease has been
present and how well it has been
controlled.
Micro vascular, neuropathies and macro
vascular complications of DM are of
special concern for the anaesthetist.
7. Cardiovascular
Diabetics are prone to hypertention,
ischeamic heart disease, cerebrovascular
disease and myocardial infarction (MI)
which may be silent .
A high suspicion for MI throughout the
perioperative period, if unexplained
hypotension, dysrhythmias, hypoxemia, or
ECG changes develop.
8. Neurological
Peripheral neuropathies are sensory
symmetrical polyneuropathies in a glove and
stocking distribution.
Preexisting neurological deficit is important to
document.
Diabetics have increased susceptibility to
perioperative nerve injury and soft tissue
ischeamia, thus, pressure points must be
protected and patients positioned carefully.
9. Autonomic neuropathies are present in 40% of
type I and 17% type II. and 50% if diabetic and
hypertension .
It results in abnormal baroreceptor function, lack
of heart beat variability (ventricular arrythmias) .
Autonomic dysfunction worsened by :
old age, diabetes of>10 years, coronary artery
disease, or beta adrenergic blockade.
10. Autonomic dysfunction:
contributes to delayed gastric emptying
(gastroparesis) leading to unexpected
regurgitation and aspiration .
Therefore evidence of autonomic neuropathy
should be confirmed , a history of heartburn and
acid reflux , if present ,a rapid sequence
induction with cricoid pressure even for elective
procedures should be applied.
12. Airway
DM is associated with Stiff joint syndrome
(nonenzymatic glycosylation of collagen
and its deposition in joints) affecting the
temporomamdibular, atlanto-occiptal and
other cervical spine immobility and is a
predictor of difficult endotracheal
intubation.
( occure in 30% of type I diabetes).
13. Renal
DM is a leading cause of endstag renal
failure, manifested first by proteinuria.
Diabetics are at risk of acute RF
postoperatvely .
avoid nephrotoxic drugs
provide adequate hydration.
16. Infection
Diabetics are at increased risk of wound
infection, because of compromised
immune system thus strict aseptic
techniques for any procedure undertaken.
17. Diabetic Ketoacidosis
Initially give IV fluids at a rate of 15-20
ml/kg/hr (1-2 L ) during the 1 st hour, then
at a rate of 4-14ml/kg/hr(200-500 ml )..
18. • About 1/3 of the estimated fluid deficit is corrected during the first 6-
8 hours, and the remaining 2/3 over the next 24 hours.
• Following initial fluid replacement give regular insulin 0.1 U/Kg IV
bolus followed by a maintenance rate of insulin infusion, where the
calculated U/hr equals RBG divided by 150 or100 .
• The maximum rate of glucose decline is fairly constant 75-
100mg/dl/h
• When serum glucose reaches 250mg/dl, add 5% dextrose at a rate
of 50ml/hr.
• Rapid decline in serum K level occur, aggressive replacement
therapy is required.
• Bicarbonate therapy is not recommended, but it may be used for pH
less than 7.0 . 1mEq/Kg over 1-2 hours.
• Rapid correction of acidosis with bicarbonate therapy may result in
alterations in central nervous system function.
19. 2- Timing
Diabetics should be placed first on list to
minimize the fasting period.
3- Hydration
Check for dehydration and start IV fluids. avoid
Lactated Ringer's Solution because lactate may
lead to metabolic acidosis, also infusing large
volumes of normal saline can lead to
hyperchloremic acidosis.
20. 4- medication
The preoperative aim is to maintain blood
sugar levels at 110-180mg/dl and in
critically ill at 80-120mg/dl.
21. Methods of achieving glycemic
control
• Patient undergoing minor surgery (patient is expected to eat or
drink within 4hours of surgery and random blood glucose (RBG) on
admission <180mg/dl)
• Type I: -Omit morning insulin.
• -Check RBG I hour preop and hourly perioperatively then 2
hourly postoperative until eating then 4 hourly.
• -Restart subcutaneous (SC) insulin regimen with first meal.
• Type II: - Omit morning oral hypoglycemic except metformin which
should be omitted the night before because it can precipitate lactic
acidosis.
• Check RBG as above.
• Restart oral hypoglycemics with the first meal.
22. • Patient undergoing major surgery (Include
patients not falling into the above category,
emergency surgery and poorly controlled)
• Preoperatively check electrolytes especially
potassium (K) to allow sufficient time to correct
any abnormality prior surgery.
• Omit morning oral hypoglycemics or short acting
insulin. Long acting insulin should be stopped 24
hours prior surgery.
• Check RBG and K I hour preop then 2 hourly
from start of infusion, hourly perioperatively and
hourly postoperatively for 4 hours or until blood
glucose is stable then 2 hourly.
23. Insulin infusion regimens
• 1 – Alberti Regimen ( If no infusion pump
available):
• Start intravenous infusion of 10 % dextrose 500
ml plus 10 mmol KCL at rate of 125 ml/hr add
regular insulin according to blood glucose level:
if
< 90 mg/dl add 5 U;
90 – 180 mg/dl add 10 U;
180 – 270 mg/dl add 15 U;
360 mg/dl add 20 U.
24. 2 – Tight Control Regimen ( If infusion pump
available):
• Start intravenous infusion of 5 % dextrose at a rate of 50
ml/hr to dextrose insulin infusion 50 U in 50 ml infusion
pump. Set insulin infusion rate U/hr = RBG divided by
150 ( or 100 if patient is on corticosteroids or obese).
• - Postoperative: Type II: Stop infusion and restart oral
hypoglycemics once eating or drinking.
Type I: Stop infusion once eating or drinking
Calculate total daily dose (units) of insulin in the last 24
hours and divide into 3 daily doses and give SC regular
insulin, adjust the dose until blood glucose is stable.
Once stable to their normal insulin regimen.
25. Regional anaesthesia:
• less regurgitation and difficult intubation.
• early detection of hypoglycemic episodes and
rapid return of oral intake.
• Attention to avoid hypotention by ensuring
adequate hydration.
• Patient with autonomic neuropathy may not be
able to keep BP within normal range.
• For medico-legal; preexisting nerve damage
must be documented prior to block.
26. • General anaesthesia:
There are no contraindications to standard
anaesthetic induction or inhalational
agents.
If gastric stasis is suspected rapid
sequence induction is performed.
Hypotension worsens after Intravenous
induction in patient with autonomic
dysfunction.
27. The Adrenal Gland
The adrenal gland is divided into two parts
• The adrenal cortex secretes androgens
mineralcorticoid ( eg; aldesterone ),and
glucocorticoids (eg, cortisol ).
• The adrenal Medulla : secretes
catecholamines ( eg; adrenaline ,
noradrenaline, and dopamine )
28. Adrenal medullary Sympathetic
Excess
Phaeochromocytoma are catecholamine
– producing tumors derived from
chromaffin cells. 90% are found in the
adrenal medulla and the remainder in
other sites including paraganglonic
cells of sympathetic nervous system.
29. Methylation of noradrenaline to
adrenaline only occurs in the adrenal
medulla and depends on cortisol
delivered by intact portocapillary
circulation which can be disrupted by
the tumor, thus most tumor mainly
produce noradrenaline.
30. • Phaeochromocytomas are referred to
as the 10% tumor as 10 % are familial,
10% bilateral, 10% extra-adrenal and
10% malignant.
• These tumors are biochemically very
active, producing and secreting
biogenic amines mainly noradrenaline
and adrenaline.
31. • Noradrenaline secreting tumors tend to
present with severe refractory
hypertension, headaches and glucose
intolerance.
• adrenaline secreting tumors tend to
cause palpitations , anxiety and panic
attacks, sweating, hypoglycaemia,
tachycardia, tachyarrhythmias .
32. 25 – 50% of mortalities occur during
induction of anaesthesia or during
operative procedures for other causes.
33. Diagnosis:
• Urinary vanillymandelic acid , elevated level of
urinary normetanephrine and metanephrine
• Elevation of total plasma catecholamine
concentration .
• CTscan without intravenous contrast media.
MRI,or uptake of [I 131]
metaiodylbenzylguanidinne by gamma camera.
34. Anaesthetic Management
Preoperative Preparation
Catecholamine-induced vasoconstriction and
hypovolemia should be controlled by
α- blockade prior surgery. Oral
phenoxybenzamine ( non-competitive , non
selective) 10mg twice daily increasing daily to
60 – 200 mg until blood pressure is controlled.
10 – 14 days to stabilize blood pressure.
Prazosin and doxazosin ( competitive , alpha1
selective) , but the non-competitive are
preferable .
35. • Reflex tachycardia,treated by selective β1– blocker, oral
atenolol 100 mg daily .
• Never commence β – blockers prior α blockade as this
will precipitate a hypertensive crisis which is exacerbated
by the negative inotropic effects of β – blockade, this
includes labetalol which has greater β than α effect 7:1.
Phenoxybenzamine dissipates over 36 hours,
postoperatively patients remain sleepy due to persistant
central α 2 – blockade and may require large volumes of
IV fluids until blockade has worn off, thus patients better
stop the drug 24 – 48 hours prior surgery.
36. The alpha methyl p-tyrosine, competitively
inhibits tyrosine hydroxylase, which is a
rate – limiting ability of
phaeochromocytoma to react to
stimulation. It can be used for patients with
poor left ventricular function .
this drug may cause severe side effects
including diarrhea , fatigue and
depression.
37. Roizen et al have recommended the following
criteria for optimal preoperative control:
1 – Blood pressure consistently < 160 / 90 mmHg
2 – Orthostatic hypotension not < 80 / 45 mm Hg,
3 – Absence of ST – T changes in ECG for at
least 1 week
4 – No more than one ventricular ectopic every 5
minute.
38. • Premedication: Benzodiazepine
• If bilateral adrenalectomy is possible
coverage with glucocorticoids and
mineralocorticoids should be planed
• Surgical approach: can be performed
using open lateral retroperitoneal
approach or, laparascopic.
39. Techniques and monitoring:
Large caliber IV cannulae ,arterial catheter
central venous catheter , but pulmonary
artery catheter is indicated only in the
presence of significantly impaired
myocardium.
Epidural catheter is placed for
perioperative analgesia (T9-L1)
Urinary catheter .
40. Anaesthesia
general anaesthesia,
Sevoflurane and isoflurane have been used extensively.
Halothane can result in severe arrhythmias .
Desflurane causes significant sympathetic stimulation
and best avoided.
Propofol, thiopental and etomidate accepted.
Indirect sympathomimetics as ketamine, pancuronium
and ephedrine, should be avoided.
Drugs that cause histamine release as morphine and
atracurium have infrequently been reported to trigger
crisis.
Isoflurane – remifentanil .
41. Tumor manipulation can produce increases
in plasma catecholamine up to 200 times
normal.
Phentolamine, a competitive α1, weak α 2
adrenoceptor, 1 – 2 mg IV boluses( slow
onset , long duration , with tachyphylaxis )
42. • Sodium nitroprusside 0.5-10 Mig/kg/min
( rapid onset , short duration , cyanide
toxicity in high doses > 0.5mg/kg/hour )
or nitroglycerin.
43. • Magnesium sulphate (antiarrhythmic properties due to calcium
channel blockade, regulation of intracellular potassium and ATP
activation).
It causes vasodilation by blocking the adrenoceptor response to
noradrenaline and angiotensin II.
It also inhibits catecholamine release from adrenal medulla and
peripheral adrenergic nerve terminals.
The effective plasma concentration is 2 – 4 mmol/litre , IV loading 40
– 60 mg/Kg followed by infusion 2 g/hour.
Side effects potentiation of neuromuscular blockade, inhibition of
platelet activity. narrow therapeutic window .
44. • Adrenaline induced tacharrhythmias are
controlled with esmolol or labetalol.
• Nicardipine
45. Hypotension sudden fall in blood
pressure after clamping vessels.
ensure euvolaemia.
vasopressors and glucose should be
available.
46. Postoperative management:
Patients should be managed in ICU .
postoperative complications include hypertension,
hypotension and hypoglycemia.
Catecholamine secretion from the contralateral adrenal
gland will be down regulated for some time.
Hypoglycemia may occur due to abrupt cessation of α 2 –
mediated pancreatic β cell inhibition. Persistant β –
blockade may mask hypoglycemic symptoms
glucose monitoring is recommended
47. Adrenocortical Malfunction
The adrenal cortex is responsible for the
secretion of three classes of steroids :
glucocorticoids, mineralocorticoids and
androgens.
48. Hyperaldosteronism
Primary hyperaldosteronism (Conn's dyndrome),
there is excess secretion of aldosterone from an
adrenal adenoma (60%), bilateral hyperplasia
(30%) or, rarely, carcinoma.
Secondary hyperaldosteronism high plasma
concentration of rennin and aldosterone.
(congestive cardiac failure and liver cirrhosis
and nephrotic syndrome.)
49. Hypertension
Increase extracellular fluid volume.
malignant hypertension (centrally or direct effect
on vascular endothelium via aldosterone-
induced vascocnstriction.
Hypokalaemia, exacerbated by treatment of
hypertension with diuretics.
Metabolic alkalosis due to hydrogen ion loss
50. Treatment
Spironolactone 400 mg day,
Manipulation of the adrenal gland may
cause secretion of catecholamines
Replacement corticosteroid and
mineralocorticoid therapy is required for all
patients undergoing bilateral
adrenalectomy and occasionally in those
undergoing unilateral .
51. Cushing's syndrome
• Cushing's syndrome is caused by
excessive levels of glucocorticoids
• Intrinsic hyperfunction of adrenal cortex
(adrenocortical adenoma ), ACTH
production by a non-pituatery tumor, or
hypersecretion by a pituatery adenoma
(cushing disease)
• exogenous administration
52. poorly controlled hypertenssion
obesity; sleep apnoea,,suspect difficult intubation.
Impaired glucose tolerance and D.M.
Hypokalaemia due to sodium retention and potassium
loss.
• Gastrooesophageal reflux
• Extra care should be taken with positioning because
there is susceptibility to pressure sores and fractures
because of fragile skin and osteoporosis
• If the Cushing's syndrome is iatrogenic, an additional
dose of steroids may be required preoperatively.
53. Addison's disease
Primary adrenal insufficiency is characterized
by reduced or absent secretion of
glucocorticoids, associated with deficient
mineralocorticoid activity.
Destruction of the adrenal cortex by
autoantibodies is the cause in 80% of cases;
other causes include tuberculosis, metastatic
carcinoma, bilateral adrenalectomy and
haemorrhage (e.g. meningococcal sepsis).
54. Patient clinical manifestation are due to
aldesterone deficiency ( hyponatrtremia ,
hypovolemia ,hyperkalemia and metabolic
acidosis)
cortisol deficiency ( weakness , fatigue ,
hypoglycemia , hypotension , and weight loss )
Increased pigmentation of palmar areases and
buccal mucosa due to high plasma levels of
ACTH that mimic melanocyte – stimulating
hormone.
55. Etomidate suppresses adrenal function by
inhibiting enzymes that are essential for
the production of corticosteroid hormones.
Etomidate therapy can lead to
glucocorticoid deficiency.
56. Scondary hypoadrenalism results from
prolonged corticosteroid therapy and
hypopituitarism
Serum potassium and glucose cheked
regularly .
For major surgery, blood glucose should
be checked every 4 h and electrolytes
should be measured daily.
57. The adequate steroid coverage is
controversial , while adults normally
secrete 20 mg of cortisol daily this may
increase to be 300 mg under maximal
stress .
58. All patients who have received potentially
suppressive doses of steroids equivalent
to 5 mg of prednisolone by any rout
(topical , inhalation , or oral ) for a period
of more than 2 weeks any time in the
previous 12 months should be considered
unable to respond appropriately to surgical
stress.
59. • For minor surgery I.V. hydrocortisone 25 mg
should be given at induction. is sufficient.
• For intermediate surgery, such as
hysterectomy, 100 mg infusion or four doses of
i.v. hydrocortisone 25 mg should be given over
the first 24 h after surgery.
• For major surgery, 200 mg of i.v. hydrocortisone
should be administered each 24 h until the
patient can be re- started on maintenance
therapy.
60. Acute Addisonian crisis
Any stressor can precipitate an adrenal crisis in
patients with adrenal suppression, surgery,
trauma, and sepsis , long-term corticosteroid
therapy discontinuation.
Treatment is of 200mg is followed by 100 mg
every 6 h until oral supplements can be taken.
Fluid resuscitation is required, and dextrose may
be necessary to treat hypoglycaemia.