Pre Anesthetic Evaluation in Dm - Liya Abraham

8/6/2019 Pre Anesthetic Evaluation in Dm - Liya Abraham

1/16

PRE ANESTHETICPRE ANESTHETIC

EVALUATIONEVALUATION

FOR

DIABETES MELLITUSLIYA ABRAHAM


2/16

INTRODUCTIONINTRODUCTION Diabetics come for surgeries for common

problems and also for procedures prompted by

long term complications They face several challenges due to imbalance

between insulin and its counter regulatory

hormones secreted during stress

Hypo tension , hypovolemia , acidosis, in post op

period face poor wound healing , ARF and

infection


3/16

PREANESTHETIC EVALUATIONPREANESTHETIC EVALUATION

HISTORY:

History specific to diabetes: polyuria,polydipsia, weight loss weakness

Known diabetic duration since onset

H/o infections skin boils carbuncle, fevercandidiasis , burning micturition,non-healing foot ulcers etc.

H/s/o episodes of unconsciousness

H/o events precipitating DKA likeinadequate insulin ,infection- UTI, RTI ,GE,SEPSIS


4/16

History of chronicHistory of chronic

complicationscomplications

Diabetic retinopathy: h/o diminution or loss

of vision Diabetic neuropathy: Mononeuropathy- 3rd

6th or 7th nerve involvement

Peripheral neuropathy- sensory loss gloveand stocking type


5/16

History of autonomic neuropathyHistory of autonomic neuropathy

dizziness, lightheadedness, diminution of vision

on standing , syncope and heat intolerance

Gastro paresis: anorexia, nausea, vomiting early

satiety or abdominal bloating Genitourinary dysfunction: cystopathy which

includes hesitancy decreased voiding frequency

incontinence and recurrent UTI,

Erectile dysfunction, retrograde ejaculation or

female sexual dysfunction


6/16

History contd..History contd.. Drug history: OHA name ,dosage and timing of

ingestion Insulin type dosage and timing details

Details of all other co morbidities IHD,HTN,CRFand medications

Past history: hospitalizations in past anycomplications and details

Family history : of diabetes

Personal history regarding dietary intake if high

calorie diet - may be on higher dose medication andec dose required pos op during fasting also askfor the extent of daily physical activity as inc doserequirement when phy activity limited

perioperatively


7/16

Clinical examinationClinical examination General- nourishment and built

Vitals : Pulse resting tachycardia

_ irregularity

_ changes with deep breathing,

valsalva and sustained hand grip

Blood pressure- look for orthostatic hypotension

Urine output

Temperature increased in infections


8/16

Systemic examinationSystemic examination RS : AIRWAY:

specifically look for stiff jointsprayer sign/ palm print sign

IP joint stiffness $ cervical joint

stiffness

Look specifically for any signs of resp tractinfections

CNS: - detailed examn including

- cranial nerves for mononeuropathy- sensory loss

-muscle wasting

- sup and deep tendon reflexes


9/16

InvestigationsInvestigations

Urine routine: glucose, albumin, ketonebodies, microscopy

Blood glucose levels: FBS, PPBS, HbA1c

Renal function: BUN, serum creatinine,serum electrolytes

CVS ECG, lower threshold for stresstesting and ECHO

Tests for autonomic neuropathy- Breathing tests ,Tilt-table test , Quantitative sudomotor axonreflex test (QSART ), Thermoregulatory sweat

test, Ultrasound.


10/16

Pre operative instructionsPre operative instructions NPO for 8 hrs . They should preferably be 1st on

the list to prevent prolonged fasting an

hypoglycemia an if prolonged blood glucose hasto be monitored

Ranitidine and metoclopramide are given night

before an day of surgery to dec acid secretion and

promote gastric emptying

FBS, SE and UKB on the morning of surgery


11/16

Adjustment of diabetes medicationAdjustment of diabetes medication

Type 2 diabetes on diet control for short electiveprocedures no treatment only blood glucose

monitoring

Patients on OHA s like newer generation

sulfonylureas(ex.glyburide, glipizide) andthiazolidinediones(ex. Rosiglitazone, pioglitazone)

OHA withheld on the morning of surgery

Metformin should be stopped 24 hrs before the

procedure to prevent the possibility of lactic

acidosis if the patients renal function gets

compromised


12/16

Adjustment of diabetes medicationAdjustment of diabetes medication

Patients on insulin- minor procedure skip the

morning dose of insulin

Patients undergoing major surgeries with longer

recovery periods on either OHA s or on long

acting insulin should be discontinued and started

on a regimen of short acting insulin

All type 2 diabetics uncontrolled or undergoingmajor surgeries are managed like insulin

dependent diabetics


13/16

Insulin therapyInsulin therapy

Non tight regimen At 6am on the day of surgery start 5% D

maintenance rate and the morning dose

of insulin is given subcutaneously

Tight control regimen

Regimen 1:

5%D started @ 50 cc/hr piggyback insulin infusion (50u in 250ml

NS) insulin rate(u/hr) = plasma

glucose(mg/dl)/150


14/16

Insulin therapyInsulin therapy

GIK regimen- Alberti and Thomas Initial 500ml 10% D +10mmol Kcl+15U

insulin @ 100ml/hr

Glucose 11.1soln with 20u @4 u /hr


15/16

Emergency proceduresEmergency procedures

Type 1 pt with ketoacidosis or type 2 pt withhyperosmolar coma requires stabilization beforesurgery unless an acute emergency

Dehydration electrolyte imbalances have to beadequately corrected

Ketoacidosis should b allowed to resolve and ptshould be stabilized on GIK regimen if surgery isnot life saving

In case of pressing surgical conditions likevascular injury or intra abdominal emergency , therisks of delay must be weighed against incompletemetabolic resolution and the surgical stress indeciding the optimum time for surgery.


16/16

Pre Anesthetic Evaluation in Dm - Liya Abraham

Documents

Transcript of Pre Anesthetic Evaluation in Dm - Liya Abraham