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.
Perioperative management of diabetes mellitusSourav Mondal
A detailed stepwise approach for the perioperative management of diabetes mellitus.
Sources taken from latest edition of Harrison, Millers, Stoeltings and ADA Guidelines.
By a anaesthetist, for a anaesthesist
Perioperative management of a patient with diabetes mellitusrajkumarsrihari
Anesthetic implications in a patient with Diabetes Mellitis with latest updates taken from british journal of anesthesia on perioperative glycemic control (2013)
Perioperative management of diabetes mellitusSourav Mondal
A detailed stepwise approach for the perioperative management of diabetes mellitus.
Sources taken from latest edition of Harrison, Millers, Stoeltings and ADA Guidelines.
By a anaesthetist, for a anaesthesist
Perioperative management of a patient with diabetes mellitusrajkumarsrihari
Anesthetic implications in a patient with Diabetes Mellitis with latest updates taken from british journal of anesthesia on perioperative glycemic control (2013)
DIABETES AND ITS ANAESTHETIC IMPLICATIONSSelva Kumar
This presentation deals with diabetes mellitus and its anaesthetic implications. All about preoperative investigations and intra-operative management are discussed.
diagnosis & complication of Diabetes mellitus including Diabetic ketoacidosis & HHS
anaesthesia managment for patient with DM posted for surgery both emergency and elective surgery
gestational diabetes mellitus
Perioperative Management of Hypertensionmagdy elmasry
Hypertension is most common medical reason for postponing surgery.How important is peri-operative hypertension?Hypertensive comorbidities associated with adverse perioperative outcomes .New Guidelines for managing patients with high blood pressure before surgery
Consequences of anesthesia on blood pressure regulation.
DIABETES AND ITS ANAESTHETIC IMPLICATIONSSelva Kumar
This presentation deals with diabetes mellitus and its anaesthetic implications. All about preoperative investigations and intra-operative management are discussed.
diagnosis & complication of Diabetes mellitus including Diabetic ketoacidosis & HHS
anaesthesia managment for patient with DM posted for surgery both emergency and elective surgery
gestational diabetes mellitus
Perioperative Management of Hypertensionmagdy elmasry
Hypertension is most common medical reason for postponing surgery.How important is peri-operative hypertension?Hypertensive comorbidities associated with adverse perioperative outcomes .New Guidelines for managing patients with high blood pressure before surgery
Consequences of anesthesia on blood pressure regulation.
Inpatient Diabetes Management - How to Control Hyperglycemia inhsopitalUsama Ragab
Inpatient Diabetes Management
By Dr. Usama Ragab Youssif
Lecturer of Medicine Zagazig University
Why we need this lecture?
Diabetes inhospital is common problem
Increased diabetes morbidities
Increased mortality
Preoperative preparation of diabetes patientDrkabiru2012
Academic presentation during junior residency rotation at Anaesthesia Department of Aminu Kano Teaching Hospita Kano, by
Dr Kabiru SALISU
kbmed2003@yahoo.com
In these powerpoints I describe how to control glycemia in the perioperative period in patient with diabetes not taking insulin. Please download these slides and view them in PowerPoint so you can view the annotations describing each slide.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
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Hot Selling Organic intermediates
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
The hemodynamic and autonomic determinants of elevated blood pressure in obes...
Perioperative Management of Diabetes Mellitus
1.
2. INTRODUCTION
• Patients with diabetes have higher
incidence of morbidity and mortality.
• Poor peri-operative glycamic control
increases the risk of adverse outcomes.
• Treatment of post-operative
hyperglycaemia reduces the risk of
adverse outcomes.
3. METABOLIC SEQUELAE IN A
SURGICAL PATIENT
Metabolic effects of starvation:
Period of starvation induces a catabolic state.
It will stimulate secretion of counter- reguletory
hormones.
It can be attenuated in patients with diabetes by infusion
of insulin and glucose(approximately 180g/day).
Metabolic effects of major surgery:
It causes neuroendocrine stress response with release of
counter-regulatory hormones
(epinephrine,glucagon,cortisol and growth hormone)and
of inflammatory cytokines IL-6 and TNF-alpha.
4. Hypoglycaemia-exacerbate the catabolic
effects of surgery.
These neurohormonal changes result in
metabolic abnormalities includes:
Increased insulin resistance.
Decreased peripheral glucose utilisation.
Impaired insulin secretion
Increased gluconeogenesis and glycogenolysis.
Increased lipolysis.
Protein catabolism,leading to
Hyperglycaemia and even ketosis in some
5. Hypo and hyperglycemia.
Multiple co-morbidities including microvascular and macrovascular
complications.
Complex polypharmacy Including misuse of insulin.
Inappropriate use ofintravenous insulin infusion.
Management errors when converting from the intravenous insulin infusion to
usual medication.
Peri-operative infection
Dehydration(osmotic diuresis)
Electrolyte imbalance
Has detrimental effect on CVS and renal func..
6. Factors adversely affecting Diabetes control
perioperatively
• Anxiety
• Starvation
• Infection
• Anaestheticdrugs
• Metabolic response to trauma
• Other drugs:steroids
7. Risk of DM patient during surgery
• Infection
• CV events:
Silent MI
Coronary artery disease
• Autonomic neuropathy.
8. Determinents of
management plan
1. Type of DM
2. Treatment,diet,oral antidiabetic drugs,insulin,
3. Metabolic status
4. Vascular status:cardiac,renal,cerebral
5. Surgery:
Emergency or
elective
minor or major
procedure
type of anaesthesia
postoperative oral
9. TARGETS FOR THERAPY
• Target glucose range for the perioperative period should be 80-180mg/dl(4.4-
10mmol/l)[according to ADA]
» In critically ill patient:<180mg/dl
» In stable patient:<140mg/dl
• HbA1c should be <8.5%
• Postpone elective surgery if possible if glycaemic control is poor(HbA1c>=9%)
• For major surgery, if serum glucose is >270mg/dl preoperatively, surgery should be
delayed while rapid control is achieved with IV infusion
• If serum glucose is>400mg/dl, surgery should be postponed and metabolic state
restabized.
10. GOALS OFPERIOPERATIVEGLYCAEMIC
CONTROL
• Strict glycaemic control(81-108)mg/dl:
• increase risk of hypogycaemia
• does not increase outcome.
• High bd glucose>200mg/dl
• Impaired wound healing.
11. CONSENSUS RECOMMENDATIONFOR TARGET
INPATIENT BG CONC.
Pt. Population BG Target Rationale
General surgery Fasting: 90-126mg/dl
Random: <200mg/dl
• Decrease Mortality
• Shorter Hosp. Stay
• Decrease Infection
Cardiac Surgery <150mg/dl • Decrease Mortality
• Decrease Infection
Critically ill Patient <150mg/dl • Decrease Morbidity
• Decrease Mortality
• Shorter Hosp. Stay
Acute Neurologic Disorder 80-140mg/dl Lack Of data consensuson
sp. Target
Ref: ADA, Society Critical Care Medicine
12. Planning admission
• AIM:
To minimise the fasting period
To ensure normoglycaemia
To minimise disruption to the pt”s usual
routine
• Hospital admission is needed at least 7 days
before major surgery to control bd.glucose
13. PRE-OPERATIVE
EVALUATION
Determine the type of diabetes and its management.
Ensure that the patient’s diabetes is well controlled.
Review of medications.
Ensure that the patient is capable of managing their diabetes
after discharge from hospital.
Consider the presence of complications of diabetes that might be
adversely affected by or that might adversely impact upon the
outcome of the proposed procedure.
Identify high-riskpatients requiring criticalcare
management.
14. Pre-0perative Evaluation
To Assess History/Examination Investigation
1.Blood Sugar Control
Hypo/Hyperglycemic
episodes,
Hospitalization,
Medical compliance
BS- F & PP
HbA1C
2. Nephropathy H/O- HTN, Swelling over
body, Recurrent
UTI.
Urine R/M (to exclude
Albuminuria and UTI)
RFT
3.Cardiac Status H/O- Angina/ MI , Swelling of
feet,
Exercise intolerance
ECG, CXR, ECHO
(ECG-less predictive )
4. PVD H/O- Intermittent
Claudication, Blanching of
feet,
Non healing ulcer
15. Contd..
To Assess History/Examination Investigation
5. Retinopathy H/O-Visual disturbances
↑ power of lenses
Fundus Examination
6. ANS Early satiety, abdominal
distension, Anhydrosis,
Impotence, Orthostatic
Syncope
Postural change in BP, HR
variability with exercise,
tachycardia response to
atropine
7. Metabolic &
Electrolyte
H/O- Starvation, Infection
Sign of DKA,
ABG, Urinary Ketone,
S. Electrolyte
8. Airway Scleroderma of Diabetes
Stiff Joint Syndrome
(Prayer sign, Palm Print test)
X-ray cervical spine
AP & Lateral
16. CONTD….
• Prayer Sign:
Patient is unable to approximate
the palmar surface of phalangeal
joints despite of maximal effort.
• Palm Print Test:
Degree of inter-phalyngeal joint
involvement can also be assessed
by scoring the ink impression
made by the palm of dominant
hand.
17. CLINICAL SIGNS OF DIABETIC
AUTONOMIC NEUROPATHY
Hypertension
Painless MI
Orthostatic hypotension
Lack of HR variability
Reduced HR response to atropine & propanolol
Resting tachycardia
Early satiety
Neurogenic bladder
Lack of sweating
Impotence
18. Test for autonomic neuropathy
•Heart rate variability (HRV) in response to:
Deep breathing
Standing
Valsalva maneuver
• BP response to:
1. Standing or passive tilting
2. Valsalva maneuver
19. HbA1-c
• Reflects glycaemic control over last 3 month.
• Check HbA1c 30 days before procedure.
• Set HbA1c goals for elective surgery, no established cut
off point.
• Some set target below HbA1c of 8.5
• Will be based on type of patient
• Young pts without comorbidities are expected to have an
A1C closer to 6.5 (tight control)
– Older patients with multiple comorbidities are allowed to have
A1C closer to 8.5 (loose control)
– General control recommendation from the ADA
20. Patient Education
• Medications to take the day before surgery
• Medications to take the morning of surgery
• Medications to take after returning home or to the
hospital room
• A handnote for the patient may be beneficial including
complete written instructions.
21. BEDSIDE GLUCOSE
MONITORING
• If patient are eating: before meal
• If patient on NPO:4-6 hourly
• Patient on I/V insulin:30 min to 2 hourly
• Peroperatively:hourly
• Postoperatively:every 2 hourly.
22. GENERAL PRINCIPLES
Diabetes should be well controlled prior to elective surgery.
Avoid insulin deficiency, and anticipate increased insulin requirements.
The patient’s diabetes care provider should be involved in the
management of their patient’s diabetes peri-operatively.
Patients with diabetes should be on the morning list, preferably first on the
list.
These guidelines may need to be individually modified depending on
the patient’s circumstance.
Patients should be well hydrated before the procedure
Withheld Metformin 24 hours before surgery
In non cardiac general surgery basal insulin+premeal bolus coverage has
been associated with improved glycaemic control compared to traditional
sliding scale regimen.
23. PATIENTSWHO REQUIRE INSULINTHERAPY
• patient with type1 DM must continue basal insulin replacement preoperatively:0.2- 0.3
u/kg/day of a long acting insulin.
• Patients who take both evening and morning doses of insulin should take their usual dose
of evening short-acting insulin, but reduce their intermediate- or long-acting dose by 20%
the night before surgery.
• On the morning of surgery, they should omit their short-acting insulin and reduce the
intermediate- or long-acting dose by 50% (and take this only if the fasting glucose is >120
mg/dl)
• Premixed insulin → reduce their evening dose prior surgery by 20% and reduce their
morning dose of .intermediate acting insulin by 50%
• Patients who on intermediate acting insulin only:
– Usual dose on night before surgery
– Decrease dose by 1/3,if operation is in early morning
– Decrease dose by 1/2,.if operation is in afternoon
24. MAJOR SURGERY(MORNING LIST)
• Maintain the usual insulin doses and diet the day before, and fast
from midnight.
• Omit usual morning insulin (and AHG).
• Commence an insulin-glucose infusion prior to induction of
anaesthesia .
• Measure BGL at least hourly during the intra-operative period.
• Continue the insulin-glucose infusion for at least 24 hours post-
operatively and until the patient is capable of resuming an adequate
oral intake.
25. MAJOR SURGERY(AFTERNOON
LIST)
Give a reduced dose of insulinbefore early breakfast in the
morning.(reduced bolus insulinplus 1/2 day time dose as
intermediate/long actinginsulin)
BGLs should be monitored closely in the pre-operative ward.
Commence an insulin-glucoseinfusion before induction of
anaesthesia.
26. MINOR SURGERY
Morning list
• Delay the usual morning dose of insulin
provided that the procedure is completed and
the patient is ready to eat just after the
procedure. The patient can then have a late
breakfast after the usual dose of insulin is
given.
• For later procedures, give a reduced dose
of insulin in the morning in the form of
intermediate or long-acting insulin if possible.
• If the BGL remains elevated (>10mmol/l), an I-
G infusion should be commenced.
Afternoon list
• Pre-operative insulin adjustments
similar to that for major surgery in the
afternoon.
• An insulin-glucose infusion may be
necessary if pre-operative insulin
adjustments result in hyperglycemia.
• Overnight admission may be
necessary for those with glycemic
instability or who are unable to
resume their usual diet before
discharge
27. Patients on Oral AHG Medication
(without insulin)
• Stop AHG medication on the day of surgery.
• Restart AHG medication when patients are able to resume
normal meals (except possibly metformin and thiazolidinediones
following cardiac surgery).
• Commence an I-G infusion if the BGL >10
mmol/L(180mg/dl); if surgery is prolonged and complicated;
or if the patient is usually treated with more than one oral AHG
agent.
• Subcutaneous insulin may be required post-operatively.
28. Patients on Diet Alone
• For patients whose diabetes is maintained on diet alone and
who are well controlled (HbA1c < 6.5%), no specific therapy is
required, but more frequent BGL monitoring during the peri-
operative period is recommended. During the procedure, BGLs
should be checked hourly.
• BGL remains above 10 mmol/L (180mg/dl) in the pre- or peri-
operative period, an I-G infusion should be commenced and
continued until they resume eating.
• If the patient does not become hyperglycemic following surgery,
the patients‟ BGL should be monitored every 4 – 6 hours until
they resume their usual meals.
• Patients who are hyperglycemic peri- or post-operatively may
require supplemental insulin and/or the initiation of specific AHG
29. Peroperative period
• Glucose levelmustbe maintainedin between140-180mg/dl
• Strict control(80-110mg/dl)has chance todevelopfatal
hypoglycaemia.
• BGL should be monitoredhourly.
• Switching toI/Vinsulin maybeappropriate dependingon the
type ofsurgery
• Twomainmethodsofinsulin administration:
Insulindrip/infusion(VRIII)
Insulinin combination withglucose & or potassium(GIK)
30. Peroperative
Insulin drip- short acting insulins preferred
99ml of0.9%N/S +1ml (100unit) insulin (1 unit/1ml) OR
250ml of 0.9%N/S+ 25unit insulin (0.1 unit/ml) OR
250ml 0.9% N/S+ 250U insulin (1U/ml)
Infusion rate(insulin unit perhour)=BG conc.(mg/dl)/150
32. GIK REGIMEN
• 1000ml 5% glucose (50gm) + 20 mEq of potassium + 15 U insulin.
• 100ml/hour=1600 drops/60 min=26 d/min. Insulin increment may be
needed if blood glucose>180mg%
• Potassium <= 3 mEq/l---20 mEq KCL
• Potassium 3-5 mEq/l----10 mEq KCL,if renal function is normal.
33. • Insulin-glucose infusionsshouldbe continueduntilthe patientscan resume anadequatediet.(or
atleast24 hrs)
• Postoperatively,assoonasthe patientstartseating,thosewho arenormallytreatedwithOHA may
need S/C insulin fora fewdays.
• Changing over to regulerdosing: Overlapthe IV infusionforatleasttwomorehourswiththe
subcutaneousinsulin priortodiscontinuingtheIV insulin.
• The startingdoseofbasalinsulin shouldbe50%to80% ofthepriorIV insulin totaldailydose,if
stableglycemic controlhadbeen achived withIV insulin.
• Hyperglycemia detected post-operatively in patients not previously known to havediabetes
should be managed as if diabetes was present, and the diagnosis of diabetesreconsidered
oncethepatienthasrecovered fromtheirsurgery.
35. RATEOF INSULIN INFUSION
Bedside capillary glucose (mmol/L) Initial rate of insulin infusion
(units/hour)
<4.0 0.5
(0.0 if a long acting background insulin has
been continued )
4.1-7.0 1
7.1-9.0 2
9.1-11.0 3
11.1-14.0 4
14.1-17.0 5
17.1-20 6
>20 Seek diabetes term of medical advice
36. FLUID MANAGEMENT
Aims of fluid management:
• Provide glucose as substrate to prevent proteolysis, lipolysis and
ketogenesis.
• Optimise intravascular volume status.
• Maintain serum electrolytes within the normal
ranges.
37. Intravenous Fluids
1. Dextrose saline / normal saline is used if blood
pressure is low or normal.
2. If there is hypertension half normal saline or 5 %
dextrose is given.
3. For normal metabolism 50 gm glucose is required
every 8 hours for energy and to avoid ketosis, to meet
this demand at least 1000 cc 5 % glucose every 8 h
will be required.
4. In situations requiring fluid restriction 10 % dextrose
can be infused instead of 5 % with double the dose of
insulin.
38. CONTD…
Very occasionally, the patient may develop hyponatremia without signs of fluid or
salt overload, In such cases 0.45% saline is replaced by 0.9% saline with dextrose
and potassium.
hypovolemia/hypotension – treat with crystalloids.
• 0.9% Normal saline
• Hartman solution( Gluconeogenic since lactate/acetate) not contraindicated
in diabetic(Interfere with glycemic control )
Recommendations *
• Hartmann’s solution should be used in preference to 0.9% saline.
• Glucose containing solutions should be avoided unless the blood glucose is low.
•1) Management of adults with diabetes undergoing surgery and elective procedures: improving standards- NHS(National
institute for health and clinical excellence ) APRIL 2011.
•2) Guidelines for intravenous fluid therapy for adult surgical patients(GIFTASUP )MAR 2011.
39.
40. PREOP FASTING
Atleast 6 hrs for solid foods.
Patients with gastroparesis , 12 hrs may be needed. Such patients
are given H2 receptor blocker(Ranitidine) and prokinetics
(metoclopromide).
When fasting exceeds 8-10 hrs then insulin-glucose infusion has to
be started to prevent catabolism.
Gastric emptying
(1)- in DM patients
(2)- after Metoclopromide
(3)- normal person
41. DM affects oxygen transport by causing glucose
binding to Hb.
Chronic kidney disease is asymptomatic in
diabetic and usually advanced.
Autonomic dysfunction :
• Exacerated Hypotension
• Risk of hypothermia
• Sympathetic response are blunted
• Silent MI
43. Propofol – lipid loading lead to impaired metobolism in DM, decreased lipid clearance.
Its of more concern when given in infusion.
Etomidate - decreases adrenal steroidogenesis decreased glycaemic response
to surgery.
Ketamine- may cause significant hyperglycemia
Midazolam –(high doses/infusion)
decreases ACTH & Cortisol decreased sympathoadrenal
stimulation decreased glycemic response to surgery.
Alpha-2 adrenergic agonist – decreases sympathetic outflow from hypothalamus,
decreases ACTH. improves glycemic control.
44. Contd…
Opiods – (high dose opiod anaesthesia) – offers hemodynamic, metabolic,
hormonal stability . Blocks entire sympathetic nervous system & Hypothalamo-
pituitary axis.
Inhalationals – (in vitro) halothane , isoflurane , enflurane inhibit the insulin
response to glucose in reversible and dose dependent manner.
Dexamethasone- PONV, but increases blood sugar.
NSAIDS
Aggravate gastritis(when on aspirin).
Aggravate renal dysfunction.
45. ADVANTAGES
Regional anaesthesia blunts the
increases in catecholamines
,cortisol, glucagon, and glucose.
Metabolic effects of anaesthetic
agents avoided
An awake patient – hypoglycaemia
readily detectable.
Decreased chance of Aspiration,
PONV and Thromboembolism.
Rapid return to diet and Sc
insulin/OHA
DISADVANTAGES
If autonomic neuropathy is present,
profound hypotension may occur.
Infections and vascular
complications may be increased
(epidural abscesses are more
common in diabetics)
Medicolegal concern of risk of
nerve injuries and higher risk of
ischaemic injury due to use of
adrenaline with LA
46. ADVANTAGES
– High dose opiate technique may
be useful to block the entire
sympathetic nervous system and
the hypothalamic pituitary axis.
– Better control of blood pressure in
patients with autonomic
neuropathy.
DISADVANTAGES
May have difficult airway. (“Stiff-
joint syndrome”)
Full stomach due to gastroparesis.
Controlled ventilation is needed as
patients with autonomic
neuropathy may have impaired
ventilatory control.
Aggravated haemodynamic
response to intubation.
It may masks the symptoms of
hypoglycaemia
47.
48. PREGNANCY
Pregnancy is a diabetogenic state. As pregnancy advances insulin resistance
increases.
Hyperglycemia during pregnancy has both maternal and fetal complications &
adverse outcome.
Challenges – Altered maternal physiology & disease associated with pregnancy.
• Maternal hyperglycaemia :
Increases the risk of neonatal jaundice.
The risk of neonatal brain damage, and
Fetal acidosis if the fetus becomes hypoxic
50. Need tighter control.
• Premeal- 60-90mg/dl.
1 hr pp - < 140mg/dl.
2 hr pp - < 120mg/dl.
More prone for hypoglycemia /hyperglycemia
DKA – usually occurs during 2nd/ 3rd trimester, even develops with
low glucose value of 200mg/dl.
52. DKA
BG≥ 250 mg/dl
Acidosis-pH<7.3
Serum HCO3<15meq/l
Serum Ketone>7meq/l
Osmolarity-300-320
K+ ↑/ ↓
Urine may be positive for
ketone body.
↑ anion gap metabolic acidosis
↑ serum amylase
53. Insulin replacement-
0.1U/kg bolus followed by 0.1U/kg/hr and if BG does not ↓ by 10%-repeat
the loading dose –if still no response –double the infusion dose in every 2 hr.
Fluids:
0.9% NS-1-2 ltr in 1st hr
0.45%NS-2-5 ml/kg/hr
0.45%NS - when the BG< 250 mg/dl
& 5%DS
Electrolyte:
20-30meq of K+/ hr
Replace phosphate when, <1mg/dl
54. Insulin replacement:
Less insulin require as compared to DKA 15 U i.v bolus then 0.1 U/kg/
hr
Fluids: Reqirement is more than DKA
0.9% NS-2-3 ltr in 2-3 hr
0.45%NS-2-5 ml/kg/hr
0.45%NS - when the BG< 250 mg/dl
& 5%DS
Electrolyte:
20-30meq of K+/hr concurrently
55. Blood sugar < 70 mg/dl.
Clinically Significant Hypoglycaemia
<54mg/dl.
Symptoms due to Adrenergic excess and
Neuroglycopenia.
Sweating, tachycardia/bradycardia ,
tremers, hypotension, dizziness, irritability,
seizures, or coma.
Stop insulin & give dextrose 20-30 ml
50%dextrose
HYPOGLYCEMIA
56. DM & EMERGENCY SURGERY
Usually Infected
Usually Uncontrolled
Dehydrated
Metabolic decompensated
Increased resistance to insulin
More Chances of acute Hyperglycemic complication
57. Little time for stabilisation of patients ,but if 2-3 hr available
• correction of fluid and electrolyte imbalance .
• Correct hyperglycemia.(start I-G infusion if sugar > 180mg/dl)*
• Treat acidosis.
• Avoid hypoglycemia.
Surgery should not be delayed in an attempt to eliminate
ketoacidosis completely if the underlying condition will lead to
further metabolic deterioration.
•Management of adults with diabetes undergoing surgery and elective procedures: improving standards-
•NHS(National institute for health and clinical excellence ) APRIL 2011
58. Contd…
If enough time is not available – correction of hydration status ,
electrolytes, acidosis, blood sugar should be started & should achieve
an improving metabolic trend before starting anaesthesia.
Likelyhood of intra-op hypotension and arrhythmia is more particularly
if pt has pre-op acidosis or hypokalemia.
Intra-op sugar to be monitored more frequently.
Atleast hourly.
LSCS – every 30 min.*
•Management of adults with diabetes undergoing surgery and elective procedures: improving standards-
•NHS(National institute for health and clinical excellence ) APRIL 2011
60. CONTD…
Since no randomised trails demonstrate superiority of any
fluid, and until there are clincal studies to verify safest
solution
THE RECOMMENDATION IS
0.45%SALINE,5%DEXTROSE&0.15%KCL as first choice.
FOR PATIENTS NOT REQ VRIII
Ringers lactate/acetate, Hartmanns solution is used.
0.9%saline hyperchloremic acidosis.
•Management of adults with diabetes undergoing surgery and elective procedures: improving standards-
•NHS(National institute for health and clinical excellence ) APRIL 2011