Perioperative Management of Diabetic Patient - Dr PSN Raju
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Perioperative Management of the
Diabetic Patient
Dr.Masthanamma.C
Dr.Raju.P.S.N
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Outline
• Definition
• Statistics
• Diagnostic criteria
• Physiology of glucose metabolism
• Complications of diabetes
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Outline
• Pre - anaesthetic evaluation
• Problems faced by a diabetic for surgery
• Goals and methods of achieving periop glycemic control
• Anaesthetic technique and the diabetic patient
• Medical / legal pitfalls
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DEFINITION
• Diabetes mellitus is defined as a syndrome characterized by sustained hyperglycemia due to insulin deficiency, impaired insulin action or a combination of both.
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Recent statistics
• Diabetes currently affects 246 million people worldwide and is expected to affect 380 million by 2025.
• In 2007, the five countries with the largest numbers of people with diabetes are
• India (40.9 million)
• China (39.8 million)
• United States (19.2 million)
• Russia (9.6 million)
• Germany (7.4 million).
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Recent statistics
• Each year 3.8 million deaths are attributable to DM.
• Cardiovascular disease is the major cause of death in diabetes, accounting for some 50% of all diabetes fatalities, and much disability.
• Every 10 seconds a person dies from diabetes-related causes.
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Diagnostic criteria for diabetes according to ADA/WHO guidelines
1 mmol = 18 mgs
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• Type 1 DM :– absolute insulin deficiency, – unopposed catabolic action leads to
hyperglycemia and diabetic ketoacidosis.
• Type 2 DM:– peripheral resistance to insulin,– less susceptible to developing ketoacidosis.
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• Mortality / morbidity rates in diabetics have been estimated to be up to 5 times greater than in
nondiabetics
Related to the end-organ damage.
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COMPLICATIONS OF DIABETES
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• DM is an independent predictor of postop myocardial ischemia and infectious complications in patients undergoing surgery.
• The ultimate goal in the management of diabetic patients is to achieve equivalent outcomes as those patients without DM.
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• A strong grasp of the complexities of glucose insulin interrelationship and of the effects of anesthesia and surgery is essential to optimal
management and outcomes.
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PHYSIOLOGY OF GLUCOSE METABOLISM
• Glucose metabolism is largely a function of the liver, the pancreas, and, to a lesser degree, peripheral tissue.
• Role of liver in glucose regulation: • Extracts glucose • Stores it in the form of glycogen • Performs gluconeogenesis • Glycogenolysis.
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• Pancreas secretes counterregulatory hormones:
– Insulin from islet beta cells, which lowers blood glucose concentrations.
– Glucagon from islet alpha cells, which raises blood glucose concentrations.
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• Additional contributors to glucose metabolism include the catabolic hormones: epinephrine, glucocorticoids, and growth hormone, which all raise blood glucose concentrations.
• Peripheral tissues participate in glucose metabolism by extracting glucose for energy needs, thus lowering blood glucose levels.
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PREOPERATIVE ASSESSMENT
• Suggestive symptoms - polyuria/polydipsia, blurred vision
• Current Rx of diabetes, including medication regimen, diet, and glucose monitoring results
• Frequency, severity, and etiology of acute complications (ketoacidosis / hypoglycemia)
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• Prior or current infections (eg, skin, foot, dental, genitourinary)
• Symptoms and treatment of chronic eye; kidney; nerve; genitourinary, bladder, and GI function; heart; peripheral vascular; foot; and cerebrovascular complications
• Nondiabetic medications that may affect blood glucose levels (eg, corticosteroids)
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Preanaesthetic evaluation
• Severity and type of the diabetic state
• Anti-diabetic Medications
• Control of blood sugar
• Treatment regimens used
• Associated complications of DM
• Airway assessment
• Comorbid conditions
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physical examination
• Orthostatic hypotension - sign of autonomic neuropathy.
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Autonomic neuropathy
• Most commonly a distal symmetrical sensory polyneuropathy with a variable degree of autonomic involvement.
• Autonomic dysfunction, which is of particular importance to the anaesthetist, is detectable in up to 40% of type 1 and 17% of type 2 diabetic
patients
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Pathogenic mechanisms for ANP
• Local ischaemia,
• Tissue accumulation of sorbitol
• Altered function of neuronal Na+/K+-ATPase activity
• Immunologically mediated damage
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• Diabetic gastroparesis is characterized by a delay in gastric emptying without any gastric outlet obstruction.
• The increased amount of gastric contents enhances the risk of acid aspiration during the induction of anaesthesia
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Fundoscopic examination
• Gives insight into the patient's risk of developing postop blindness, especially following major prolonged surgery.
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stiff joint” syndrome,
• Significant risk during airway management.
• Affects temporomandibular, atlantooccipital, and other cervical spine joints.
• Short stature and waxy skin.
Related to chronic hyperglycemia and nonenzymatic glycosylation of collagen and its deposition in joints.
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• A positive “prayer sign” can be elicited on examination with the patient unable to approximate the palmar surfaces of the phalangeal joints while pressing their hands together;
• Represents cervical spine immobility and the potential for a difficult endotracheal intubation .
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• Further airway evaluation should include assessment of thyroid gland size, as patients with type 1 DM have a 15% association of other autoimmune diseases, such as Hashimoto thyroiditis and Graves disease.
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• The degree of preoperative neurological dysfunction is important to document, especially prior to regional anesthesia or peripheral nerve blocks, to assess the degree of subsequent nerve injury.
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lab evaluation
• Fasting serum glucose concentration
• HbA1c
• Serum electrolytes
• Blood urea nitrogen
• Creatinine.
• Urinalysis - assess for proteinuria and microalbuminuria.
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• Studies have shown a correlation between preop
proteinuria and postop death after CABG, with
the mortality rate increasing proportionally with
the concentration of protein in the urine.
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• Based on the nature of surgery, ECG assessing R-R interval during respiration may be useful in the evaluation of autonomic neuropathy.
Loss of R-R variability when the HR at maximal inspiration is compared with the HR at maximal expiration implies the presence of autonomic cardiac neuropathy.
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GENERAL PREOP MANAGEMENT
• On the day of surgery, patients on oral regimens should be advised to discontinue these medications.
Sulfonylureas, meglitinides have the potential to cause hypoglycemia.
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• Sulfonylureas have been associated with interfering with ischemic myocardial preconditioning and may theoretically increase risk of perioperative myocardial ischemia and infarction.
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• Patients taking metformin should be advised to discontinue this drug because of the risk of developing lactic acidosis.
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• For these patients, short-acting insulin may be administered s/c as a sliding scale or as a continuous infusion,to maintain optimal glucose control, depending on the extent of surgery.
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• Patients who are insulin-dependent (type 1)
should be advised to reduce their bedtime
dose of insulin the night prior to surgery to
prevent hypoglycemia, while NBM.
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Problems faced by a diabetic for surgery
• Surgical stress response with catabolic hormone secretion
• NBM, which may be prolonged following GI procedures
• Altered consciousness - masks the symptoms of hypoglycaemia
• Circulatory disturbances - which may alter the absorption of s/c insulin.
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METABOLIC RESPONSE TO ANESTHESIA AND SURGERY
• Surgery induces a considerable stress response mediated by the neuroendocrine system through the release of catecholamines, glucagon, and cortisol.
• The principal mechanism lies with the elevation of sympathetic tone with a subsequent release of cortisol and catecholamines during surgery.
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• A nondiabetic patient is able to maintain glucose homeostasis by secreting a corresponding amount of insulin to balance the glucose
generated by the stress response.
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• This compensatory mechanism in diabetic patients is impaired through a relative insulin deficiency (type 2) or absolute insulin deficiency (type 1) necessitating supplementation of insulin in the perioperative period.
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• Anesthetic agents can affect glucose metabolism through the modulation of sympathetic tone; in vitro evidence suggests that inhalational agents suppress insulin secretion.
• The resulting relative insulin deficiency often leads to glucose dysregulation and hyperglycemia.
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• The use of regional anesthesia or peripheral nerve blocks may mitigate these concerns, but no data suggest that these forms of anesthesia will improve postoperative survival in patients with DM.
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GOALS OF PERIOPERATIVE GLYCEMIC CONTROL
• The goals for glycemic control are tailored to each patient based on:
• Nature of surgery, • Severity of underlying illness, • Modality used to achieve glycemic control• Patient age, • Sensitivity to insulin.
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• Prior to elective surgery, it is ideal for patients to have their HbA1c < 6%.
• Less intensive glycemic control may be indicated in patients with severe or frequent episodes of hypoglycemia.
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Methods of Achieving Glycemic Control
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• Intravenous insulin is the most flexible and readily titratable agent, with few, if any, contraindications, making it an ideal agent for perioperative use.
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• The length, type of surgery, and degree of glycemic dysregulation will dictate the degree of supplemental intravenous insulin therapy.
• Patients with type 1 diabetes should have elective surgeries scheduled as the first case of the day to minimally disrupt their DM regimen.
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• Administer half of their daily dose of long-acting insulin.
• Arrive at the preop admitting area early enough to have an I.v infusion of dextrose instituted and their serum glucose monitored until the time of surgery.
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• Establish separate iv access for a “piggyback” infusion of regular insulin .
• The infusion rate can be determined by using the formula: insulin (U/h) = serum glucose (mg/dL)/150.
• Intravenous glucose solution should be administered concomitantly to avoid hypoglycemia.
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• Typically, a 5% D solution is started when serum glucose levels are less than 150 mg/dL.
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• Patients suspected of gastroparesis should receive a prokinetic drug prior to general anesthesia to decrease the incidence of gastric acid aspiration.
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• Aseptic technique is critical for all procedures in patients with DM to decrease the incidence of postoperative infection.
• Temperature control is also essential in patients with DM, as hypothermia can lead to peripheral insulin resistance, hyperglycemia, deceased wound healing, and infection.
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• Intraop management of intravascular volume may require the use of a central venous pressure catheter, a pulmonary artery catheter, or TEE to best guide therapy and to protect against end-organ hypoperfusion.
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• Arterial blood gas analysis should not only include assessment of blood glucose levels but also levels of sodium, potassium, and assessment of pH.
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• Type 1 diabetic patients are predisposed to developing ketoacidosis during periods of major stress; therefore, they should be monitored by arterial blood gas analysis during and after major surgery.
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General guidelines for periop control of diabetes
• Check blood glucose, urea, electrolytes and urinary ketones
• Adjust insulin therapy BD – soluble isophane insulin
• Poor control: change to TID – soluble insulin and delay elective surgery
• Urgent surgery: glucose insulin infusion
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Day of surgery
• Check fasting sugar
• No subcutaneous insulin
• Start 10% D (500ml) with 10 U human insulin and KCI 1Ommol for 4-6 h
• Adjust insulin according to the blood sugar values <4 No insulin4-6 Insulin 5 U / 500 mL 10%glucose6-10 Same as above10-20 15 U/ 500 Ml 10% glucose>20 20 U/500 mL 10%glucose
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• K+ is adjusted according to serum K+
K+<3 mmol/L add 20 mmol K+/500 ml
K+>5 mmol/L no KCI
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Postop major surgery
• Check blood sugar every 2-6 h
• Check urea, electrolytes every 4-6h
• Continue infusion till oral feeding is established
• If feeding is delayed, change to 20% glucose with less volume
• When oral diet is established, q8h soluble insulin prior to each feed
• When insulin requirements are stable,restart the preoperative regimen
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Emergency surgery and DKA
• DKA results from inadequate insulin dosage or increased insulin requirement often precipitated by trauma, infection or surgical stress.
• Administer insulin at the rate of 4-8U/hr, depending on factors such as blood sugar levels, ketosis and acidosis.
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• Correct dehydration, sodium depletion and subsequent potassium depletion
• Replace fluids with isotonic solution of NaCI 1 L in 30 min,1 L in the next hour and further 1 L over the next 2 hours.
• Monitor blood glucose levels, arterial pH and blood gases
• K+may be normal or elevated due to presence of acidosis
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• Magnesium 5-10 mmol is also required along with K+ depletion.
• 5% D can be started when blood glucose decreasesto 15 mmol/L
• Surgery is ideally carried out after reversal of acidosis and hyperglycemia.
• However, if the indication for surgery is emergent, surgery can be started when volume resuscitation is underway, with the diabetic management being continued in the intraop and postop periods.
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Tight control of blood glucose
• Tight control of blood sugar between 80 – 120 mgs/dL
– Prevents ischemia– Improves wound healing– Improves weaning from CPB
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REGIMEN - 1
• Preprandial sugar levels on the evening before surgery.
• Start infusion of 5% D at the rate of 50 ml/hr
• To this infusion, piggyback regular insulin 50 U in 250 ml 0.9 Nacl.
• Set the infusion rate U/hr = Plasma glucose 150
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REGIMEN - 1
• Repeat glucose values q4h, and adjust insulin infusion to achieve plasma glucose of 100-200 mg/dl.
• Intraop - use non dextrose containing fluids.
• Determine plasma glucose q2h and adjust insulin accordingly.
• Serum K+ should be checked and adjusted accordingly with particular care for poor renal function.
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Anaesthetic technique and the diabetic patient
• Regional blockade, may modulate the secretion of the catabolic hormones and any residual insulin secretion.
• The periop increase in circulating glucose, epinephrine and cortisol concentrations found in non-diabetics exposed to surgical stress under GA is blocked by epidural anaesthesia
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• The perioperative infusion of phentolamine, a competitive -adrenergic receptor blocking drug, decreases the glycaemic response to surgery by partially reversing the suppression of insulin secretion
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• Regional anaesthesia may carry greater risks in the diabetic patient with autonomic neuropathy.
• Profound hypotension may occur with deleterious consequences in a patient with co-existing coronary artery, cerebrovascular or renovascular disease
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Medical / Legal Pitfalls
• Overtreatment or undertreatment of hypoglycemia, eg, premature discharge of a patient who develops hypoglycemia due to a sulfonylurea agent, is a pitfall.
• Failure to record the blood glucose levels of patients with wounds or active infections when they are <250 mg/dL is a pitfall and may lead to poor healing.
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Medical / Legal Pitfalls
• Failure to provide adequate hydration to patients with mild diabetic nephropathy before contrast material is given may precipitate acute renal failure.
• Failure to examine the patient's feet and failure to detect small ulcers or underestimation of their seriousness are also pitfalls.
• Failure to consider myocardial ischemia in patients with nonspecific symptoms is a pitfall.
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Conclusions
• There have been major advances in the last few years in understanding and treating complications of diabetes.
• The main focus has been on good glycemic control.
• The incidence of diabetes is on the rise in most populations, with Indians being more prone to develop diabetes.
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• Diabetes mellitus is likely to be the most common comorbid factor encountered in Surgical practice.
• A clear understanding of the metabolic process, well controlled glycemic regimens and excellent periop care will go a long way towards decreasing the mortality and morbidity in diabetes patients.
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