DEPARTMENTAL PRESENTATION

1. ANAESTHETIC IMPLICATIONS IN
DIABETES MELLITUS
PRESENTERS - SQN LDR M MISHRA
MAJ SHREYAS KATE
MAJ R N HOTA
MODERATOR - LT COL DEEPAK DWIVEDI

2. REFERENCES
• Miller’s Anaesthesia by Ronald D. Miller
• Stoelting’s Anaesthesia & Coexisting Disease
• G. R McAnulty, Anaesthetic management of patients with Diabetes
Mellitus, BJA, Vol 85, Issue 1, July 2000
• Bajwa SJS, Kalra S. Diabeto-anaesthesia: A subspecialty needing
endocrine introspection. Indian Journal of Anaesthesia.
2012;56(6):513-517
• J.J Sebranek, Glycaemic control in the perioperative period, BJA,
volume 111,Dec 2013.
• *PERIOPERATIVE DIABETES MANAGEMENT GUIDELINES-
AUSTRALIAN DIABETES SOCIETY MAY 2012

3. GOALS
 Establishment of certain glycemic target levels,
<180 mg/dL in critical patients and < 140 mg/dL in
stable patients.
 Avoidance of severe hyperglycemia or hypoglycemia.
 Prevention of ketoacidosis.
 Maintenance of physiological electrolyte and fluid
balance.
 Reduction of overall patient morbidity and mortality.
Stoelting Coexisting- 6 e

4. Preanaesthetic Evaluation
• Severity and type of disease.
• Anti diabetic medication.
• Control of blood sugar.
• Treatment regimens used.
• Associated complications of DM.
• Airway assessment.
• Assessment of the Autonomic Nervous System.
• Assesment of other Comorbid conditions.

5. PRE-OPERATIVE EVALUATION
To Assess History/Examination Investigation
1. Blood Sugar
Control
Hypo/
Hyperglycemic
episodes,
Hospitalization
BS- F &
PP
HbA1C
2. Nephropathy
H/O HTN, Edema,
Recurrent
UTI.
Urine R/E, M/E,
RFT
3. Cardiac Status
H/O Angina/ MI,
Swelling of feet,
Exercise intolerance
Resting ECG, CXR,
ECHO, TMT
4. PVD
H/O Intermittent
Claudication,
Blanching of feet,
Non healing ulcer
USG doppler

6. CONTD..
To Assess History/Examination Investigation
5. Retinopathy H/O Visual disturbances Fundus Examination
6. ANS
Early satiety, abdominal
distension, Anhidrosis,
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,
Sr. Electrolytes
8. Airway
Scleredema diabeticorum,
Stiff Joint Syndrome
(Prayer sign, Palm Print
test)
X-ray cervical
spine AP &
Lateral

7.  Palm print sign
 Prayer Sign
 Modified Mallampati Grade
 Head Extension
In diabetic patients palm print is the best single
predictor of a difficult intubation, followed by
Mallampati and the prayer sign.*
*Hashim K, Thomas M. Sensitivity of palm print sign in prediction of
difficult laryngoscopy in diabetes: A comparison with other airway
indices. Indian Journal of Anaesthesia. 2014;58(3):298-302.
doi:10.4103/0019-5049.135042.

8. 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 be assessed by scoring
the ink impression made by the palm of
dominant hand.

9. Stiff Joint Syndrome
• Significant risk during airway management.
• Affects temporomandibular, atlanto-occipital, and other
cervical spine joints.
• Short stature and waxy skin.
• Related to chronic hyperglycemia and nonenzymatic
glycosylation of collagen and its deposition in joints.

10. TESTS FOR ANS (SYMPATHETIC)
Blood Pressure Normal Value
BP Response to Standing Difference < 10mm of Hg
BP Response to Sustained
Handgrip
Difference > 16mm of Hg

11. TESTS FOR ANS (PARASYMPATHETIC)
Heart Rate Response Normal Value
Valsalva Maneuver Ratio of > 1.21
Standing Ratio of > 1.04
Deep Breathing Mean Diff > 15bpm

12. Intraoperative Metabolic Challenges
• Surgical induction of the stress response with catabolic
hormone secretion.
• Interruption of food intake, may be prolonged following
gastrointestinal procedures.
• Altered consciousness which masks the symptoms of
hypoglycemia and necessitates the frequent blood
glucose estimations.
• Circulatory disturbances associated with anaesthesia
which may alter the absorption of sub cutaneous insulin.

13. PRINCIPLES OF ANAESTHESIA
MANAGEMENT
• Timing :- First on the operating list.
• Pre operating fasting :- Delayed gastric emptying and
gastroparesis
• IV fluids :- NS, RL, balance salt solutions
• Intraoperative monitoring :- Insulin – 1 to 2 hourly
OHA – 4 hourly
• Glycosylated haemoglobin :- For pre operative
evaluation.
• Sugar control :- 100 – 180mg%

14. PRINCIPLES OF ANAESTHESIA
MANAGEMENT
• Intraoperative short acting insulin infusion :-
• (0.02 IU/Kg/Hr)
(a) In pts with absolute insulin deficiency and poorly
controlled diabetes.
(b) Substrate in the form of glucose.
(c) Maintenance fluid therapy – 5% dextrose in
0.45%NaCl with 20mmol of potassium per ltr
(1-2ml/kg/hr)
Stoelting’s 6thE

15. • Benzodiazepines
 secretion of ACTH  production of cortisol,
when used in high doses during surgery
 sympathetic stimulation but, paradoxically,
stimulate GH secretion and result in a decrease in the
glycaemic response to surgery.
Effects are minimal when midazolam is given in
usual sedative doses, but may be relevant if the
drug is given by continuous i.v. infusion to patients.
• G. R McAnulty, Anaesthetic management of patients with
Diabetes Mellitus, BJA, Vol 85, Issue 1, July 2000

16. High‐dose opiate:
 Produce haemodynamic, hormonal and metabolic
stability.
 Effectively block the entire sympathetic nervous
system and the HPA axis, probably bya direct effect
on the hypothalamus and higher centres.
 Seen in normal patients and may be of
benefit in the diabetic patient.
G. R McAnulty, Anaesthetic management of patients with Diabetes Mellitus, BJA,
Vol 85, Issue 1, July 2000

17. Etomidate:
 Blocks adrenal steroidogenesis and hence cortisol
synthesis by its action on 11 β-hydroxylase and
cholesterol cleavage enzymes and consequently
decreases the hyperglycemic response to surgery by
approx 1 mmol/L in non-diabetic subjects.
 The effects on diabetic pts have not been established.
G. R McAnulty, Anaesthetic management of patients with Diabetes Mellitus, BJA, Vol 85,
Issue 1, July 2000

18. Propofol:
 The effect of propofol on insulin secretion is not known.
 Diabetic patients show a reduced ability to clear lipids
from the circulation.
 Not relevant when propofol is used for maintenance or
as an induction agent only.
 It may have implications for patients receiving propofol
for prolonged sedation in the intensive care unit.
G. R McAnulty, Anaesthetic management of patients with Diabetes Mellitus, BJA, Vol 85,
Issue 1, July 2000

19. Ketamine:
 Ketamine has a dual effect on blood glucose level.
 Low dose produces hyperglycaemia, mediated via α2-
adrenoceptors
 High doses produce hypoglycaemia mediated through
opioid receptors with some involvement of β-
adrenoceptors that becomes evident only after
blockade of α2-adrenoceptors.
G. R McAnulty, Anaesthetic management of patients with Diabetes Mellitus, BJA, Vol
85, Issue 1, July 2000

20. Inhalationals:
 Halothane, enflurane and isoflurane, in vitro, inhibit
the insulin response to glucose in a reversible and
dose‐dependent manner.
G. R McAnulty, Anaesthetic management of patients with Diabetes Mellitus, BJA,
Vol 85, Issue 1, July 2000

21. α2 agonists:
 May decrease insulin secretion during perioperative
period – hyperglycemia.
 Dexmedetomidine and clonidine – decreases ACTH and
cortisol secretion thereby preventing hyperglycemia and
maintain haemodynamic stability.
Bajwa SJS, Kalra S. Diabeto-anaesthesia: A subspecialty needing endocrine
introspection. Indian Journal of Anaesthesia. 2012;56(6):513-517.

22. Muscle Relaxants:
 Succinylcholine should be avoided in patients with
extensive peripheral neuropathy due to risk of
increased potassium release.
 Atracurium and mivacurium are preferred in presence
of renal dysfunction.
 Rocuronium may be used in rapid sequence induction.
- Bajwa SJS, Kalra S. Diabeto-anaesthesia: A subspecialty needing endocrine
introspection. Indian Journal of Anaesthesia. 2012;56(6):513-517.

23. Dexamethasone:
 Prevents PONV but may increase blood glucose.
 After administration, tight monitoring of blood
glucose and correction of hyperglycaemia is
recommended.
 NSAIDS - Aggravate gastritis(when on aspirin).
Aggravate renal dysfunction.
Hans P, Vanthuyne A, Dewandre PY et al. Blood glucose concentration profile
after 10 mg dexamethasone in non-diabetic and type 2 diabetic patients undergoing
abdominal surgery. Br J Anaesth 2006;97:164-70.

24. GENERAL ANAESTHESIA & DIABETES
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.
 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 mask the symptoms of
hypoglycaemia

25. REGIONAL ANAESTHESIA & DIABETES
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 s/c
insulin/OHA
DISADVANTAGES
 If autonomic neuropathy
is present, profound
hypotension may occur.
 Infections may be increased
(epidural absesses are more
common in diabetes)
 Medicolegal concern of risk
of nerve injuries and higher
risk of ischaemic injury due
to use of adrenaline with LA

26. INTRAOPERATIVE GLYCEMIC
MANAGEMENT
 Surgical stress as well as anaesthesia promotes
hyperglycemia in the diabetic patients
 Literature suggests, keep BG levels 140-180 mg/dl(7.7-
10 mmol/L) during surgery.
 Intraoperative Hyperglycemia(>180 mg/dl) as well as
relative Normoglycemia (<110 mg/dl) both was found to
be associated with significant morbidity and mortality.
J.J Sebranek, Glycaemic control in the perioperative period, BJA, volume 111,Dec 2013.

27.  Glucose levels ranging from 110 to 170 mg/dL has the
lowest risk of adverse outcomes.
 For short, minor procedures, preoperative glucose
maintenance protocols may still be employed.
 For more major surgeries, variable rate IV insulin infusion
has been highlighted as a more effective method for
achieving glycemic control.
INTRAOPERATIVE GLYCEMIC
MANAGEMENT

28. MAJOR SURGERY (MORNING LIST)
 Maintain the usual insulin doses and diet the day before
and fasting 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
PERIOPERATIVE DIABETES MANAGEMENT GUIDELINES-AUSTRALIAN DIABETES
SOCIETY MAY 2012

29. MINOR SURGERY
MORNING LIST
 Delay the usual morning dose of
insulin provided that the
procedure is completed and the
patient is ready to eat by 10:00 am.
 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 preoperative insulin
adjustment result in hyperglycemia.
 Overnight admission may be
necessary for those with glycemic
instability or with those who are
unable to resume their usual diet
before discharge.

30. DIABETESCONTROLLED BYDIET
 No specific therapy is required.
 During the procedure, BGLs should be checked hourly.
 BGL remains >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 patient’s 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
• *PERIOPERATIVE DIABETES MANAGEMENT GUIDELINES-AUSTRALIAN
DIABETES SOCIETY MAY 2012

31. PATIENTS ON OHA (WITHOUT INSULIN)
 Omit OHA 24-48 hours before surgery.
 Restart it when patients are able to resume normal
meals (except metformin and thiazolidinediones
following cardiac surgery).
 Commence an I-G infusion if the BGL >180mg/dl, if
surgery is prolonged and or if the patient is usually
treated with the more than one more than one oral AHG
agent.
 Subcutaneous insulin may be required post-operatively
*PERIOPERATIVE DIABETES MANAGEMENT GUIDELINES-AUSTRALIAN
DIABETES SOCIETY MAY 2012

32. REGIMENS OF
INSULIN THERAPY

33. SLIDING SCALE REGIMEN(S/C)
Limitations:
 Little flexibility
 Variable insulin absorption
 Little rational of their use except minor surgery under
local anesthesia
Glucose in mg/dl Regular Insulin
150-200 2 unit
201-250 4 unit
251-300 6 unit
301-350 8 unit
≥350 10 unit

34. SLIDING SCALE REGIMEN I.V.
 Insulin sliding scale uses 100 U of soluble Insulin
diluted up to 100 ml with normal saline and run
at a rate according to the patient’s blood glucose.
 Dextrose and potassium also need to be infused
concurrently.
Glucose(mg/dl) Regular Insulin(ml/hr)
<120 Stop infusion
121-150 1
151-180 1.5
181-240 2
240-300 3
300-360 4
>360 6
Stoelting’s

35. The amount of Insulin
administered can be
altered easily without
having to make up a new
mixture.
DISADVANTAGE
Risk of a failure to
administer
dextrose due to
blockage,
disconnection or
backflow.
ADVANTAGE

36.  Glucose – Potassium – Insulin infusion
Alberti and Thomas regimen (1979)
To commence on the morning of surgery:
500ml 10% glucose
+ 10U Insulin + 10 mmol Kcl
@ 100ml / hr
Blood sugar every 2-3hrs
Blood sugar
<5mmol / L (90mg/dl)
Insulin ↓ to 5U
Blood sugar
>10mmol / L (180-
270mg/dl)
Insulin ↑ to 15U
ALBERTI’S GKI REGIMEN

37.  Simple
 Safe
 Reproducible
 Remove the
risk of
accidental
Insulin
infusion
without
dextrose.
• Need to change
the bag if dose of
insulin needs to be
changed.
• Insulin could be
adsorbed in the iv
fluid bag and
infusion set – could
be avoided by
flushing solution
through infusion set
ADVANTAGE DISADVANTAGE

38. MODIFIED ALBERTI REGIMEN
500ml of 10%dextrose +
10mmols of KCL +15 U
Insulin @ 100ml/hr
Cont. new GIK
solution at adjusted
conc.
Increase Insulin
by 5 U
Decrease Insulin
by 5 U
Measure
BG every 2
hrs
BG<120mg
/dl
BG >200mg/dl
BG 120-200mg
continue @ same
rate

39. TIGHTCONTROL REGIMEN
 Target Blood Sugar is 80-110 mg/dl.
 Indications: Pregnancy, CPB, Neurosurgery.
 Advantages: Improve wound Healing,
Prevent wound infection,
Improve neurological outcome.
 Night before surgery do preprandial glucose.
 Start 5% Dextrose @ 50 ml/hr.
 Dissolve 50 U of insulin in 250 ml of NS and start piggy back infusion.
 Insulin infusion rate = BG/150 U/hr and
BG/100 U/hr if pt is obese(BMI > 35 kg/m2), on steroid or in sepsis.
RISK HYPOGLYCEMIA

40. VELLORE REGIMEN
Regular insulin 5 U in 500 mL of 5% dextrose in water solution (D5W)
should be started in the ward at 8 am @ 100 mL/hr until the time of
operation.
Blood sugar (mg/dL) Treatment
<70 Stop insulin if on insulin. Rapid infusion of 100 mL of
D5W, measure blood glucose after 15 min
71-100 Stop insulin, infuse D5W at 100mL/h
101-150 1U of insulin + 100 mL of D5W/h
151-200 2U of insulin + 100 mL of D5W/h
201-250 3U of insulin + 100 mL of D5W/h
251-300 4U of insulin + 100 mL of D5W/h
>300 1U of insulin for every 50 mg more than 100 mg/dL +
100 ml of normal saline/h

41. VARIABLE RATE INTRAVENOUS INSULIN
INFUSION (VRIII)
 Formerly known as sliding scale insulin.
 Make up a 50 ml syringe with 50 units of soluble human
insulin in 49.5mls of 0.9% sodium chloride solution. This
makes the concentration of insulin 1 unit per ml.
 The substrate solution to be used alongside the VRIII
should be selected from:
• 0.45% saline with 5% glucose and 0.15% KCl, or
• 0.45% saline with 5% glucose and 0.3% KCl
JBDS guidelines,oct’2014

42. ARRANGEMENT OF INTRAVENOUS LINE FOR
INFUSION OF REGULAR INSULIN

43. VRIII(CONTD
…)
ADVANTAGES
 Accurate delivery of insulin via
syringe driver;
 Allowing tight blood glucose
control in the intra-operative
starvation period when used
appropriately;
 Flexibility for independent
adjustment of fluid and insulin.
DISADVANTAGES
× Severe hypoglycaemia
× Hyponatraemia

44. FLUID MANAGEMENT

45. Aims:
 Provide glucose as substrate to prevent proteolysis, lipolysis
and ketogenesis.
 Maintain blood glucose level between 6-10mmol/L where
possible (acceptable range 4-12mmol/L).
 Optimise intravascular volume status.
 Maintain serum electrolytes within the normal ranges.

46. RECOMMENDATIONS: PATIENTS REQUIRING A
VRIII
The substrate solution
rate intravenous insulin
to be used
infusion should be
alongside the variable
based on serum
electrolytes, measured daily and selected from:
 0.45% saline + 5% glucose + 0.15% KCL;
 0.45% saline + 5% glucose + 0.3% KCL.

47. RECOMMENDATIONS: PATIENTS REQUIRING A
VRIII
Very occasionally, the patient may develop hyponatraemia without
overt signs of fluid or salt overload. In these rare circumstances it
is acceptable to prescribe one of the following solutions as the
substrate solution:
 0.9% saline + 5% glucose + 0.15% KCl;
 0.9% saline + 5% glucose + 0.3% KCl.

48.  Ringer’s lactate: lactate undergo gluconeogenesis
in the liver and may complicate blood sugar
control when given in large volumes.
 Normal saline : hyperchloremic acidosis
 Ringer’s Acetate: acetate metabolism is unchanged
in patients with DM. rapid infusion of high
volume  vasodilation, myocardial depression.
 No ideal solution; either solution may be used
judiciously.

49. THE POST-OPERATIVE PERIOD
 Insulin-glucose infusions should be continued until the patients can resume an
adequate diet.(or atleast 24 hrs).
 I-G infusions should ideally be stopped after breakfast, and a dose of
subcutaneous insulin (or oral AHG) is given before breakfast.
 Hyperglycemia detected post-operatively in patients not previously known
to have diabetes should be managed as if diabetes was present, and the
diagnosis of diabetes reconsidered once the patient has recovered from their
surgery.
 Diabetes medication requirements may be increased (or occasionally
decreased) in the post-operative period, and frequent BGL monitoring is
therefore essential.
 Endocrinologist must be available for the post-operative
management of glycemic instability.
*PERIOPERATIVE DIABETES MANAGEMENT GUIDELINES-AUSTRALIAN DIABETES SOCIETY MAY 2012

50. ANAESTHESIA&DM
SPECIALSITUATIONS

51. DM & EMERGENCY SURGERY
 Usually Infected
 Usually Uncontrolled
 Dehydrated
 Metabolic decompensated
 Increased resistance to insulin
 More Chances of acute Hyperglycemic complication

52. EMERGENCY SURGERY
 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.

53.  If enough time is 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.*

54. 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
Maternal hyperglycaemia :
 Increases the risk of neonatal jaundice.
 The risk of neonatal brain damage, and
 Fetal acidosis if the fetus becomes hypoxic

55.  Need tighter control.
 More prone for hypoglycemia /hyperglycemia
 DKA – usually occurs during 2nd/ 3rd trimester, even develops
with low glucose value of 200mg/dl.

56. CONTROVERSIES INDM

57. GLYCEMIC CONTROL
* AMERICAN DIABETICASSOCIATION
# SOCIETY OF CRITICAL CARE MEDICINE
$ AMERICAN HEARTASSOCIATION/AMERICAN STROKEASSOCIATION
PATIENT POPULATION BLOOD GLUCOSE
TARGET
RATIONALE
GENERAL
MEDICAL/SURGICAL * FBS – 90-126mg/dl
RANDOM- <200mg/dl
Decreased mortality , infection
rates, shorter length of stay.
CARDIAC SURGERY * < 150mg/dl Decreased mortality , sternal
wound infection rates.
CRITICALLY ILL # <150mg/dl Mortality, morbidity , length of
stay.
ACUTE NEUROLOGICAL
DISORDER $
80- 140mg/dl Lack of data , concensus on
specific target, consensus for
controlling hyperglycemia.

58. TAKE HOME MESSAGES
 Ensure glycemic control.
 Proper preoperative assessment and preparation, check for
DAN.
 Avoid prolong fasting, start insulin-glucose Infusion.(keep
BG level <180 mg/dl)

59.  Careful perioperative glucose management can reduce
surgical complications as well as hyper- or hypoglycemic
sequelae
mortality.
which ultimately improves morbidity and
 Remember: Hypoglycemia is more dangerous than
hyperglycemia.

60. THANK YOU