Diabetes Mellitus: Three situations

1. Diabetes Mellitus: Three situations Love & Best Wishes to the young friends Rakesh Kumar, DA, MD Professor Anesthesiology, Intensive Care & Perioperative Medicine MAMC & Associated Hospitals, New Delhi www.anaesthesia.co.inanaesthesia.co.in@gmail.com

2. What are the diagnostic yardsticks for DM? • What is impaired fasting glycemia? • A BS of 180 mg.dl-1=How many mmol.L-1? • If venous BS is 110 mg.dl-1, what is capillary BS?

3. Reproducible demonstration of fasting hyperglycemia: FBS > 110 mg% (6.1 mmol L-1) (Serum/plasma sugar > 126 mg% [7 mmol L-1, OR • A ‘casual’ (R) BS of > 180 mg% [10 mmol L-1], OR • Oral GTT producing a result in the diabetic range. • BS concentrations between 100 – 110 mg% (5.6-6.1 mmol L-1)  ‘impaired fasting glycemia’.

4. What are the factors affecting the perioperative anesthetic management of DM?

5. Type of DM • Medication • End-organ changes • Nature of surgery • Urgency of surgery • Level of glycemic control

6. Case 1 60 year old, 60 kg man, height 165 cm; scheduled for abdominoperineal resection of Ca. rectum • Known diabetic • BG: (F) = 120, (PP) = 170 mg.dl-1 What would you want to find out from history, examination and investigations?

7. Treatment history • Two main categories of drugs? • What are their subdivisions?

8. Insulins

9. Insulins (contd..)

10. Oral antihyperglycemic drugs

11. Oral antihyperglycemic drugs (Contd..)

21. Standard of BS Control • Nephropathy • Ischemic heart disease, CHF and Cardiomyopathy • Autonomic neuropathy • Retinopathy • Stiff joint syndrome • Electrolyte & metabolic derangement

23. Standard of BS Control • Nephropathy • Ischemic heart disease, CHF and Cardiomyopathy • Autonomic neuropathy • Retinopathy • Stiff joint syndrome • Electrolyte & metabolic derangement

25. Standard of BS Control • Nephropathy • Ischemic heart disease, CHF and Cardiomyopathy • Autonomic neuropathy • Retinopathy • Stiff joint syndrome • Electrolyte & metabolic derangement

27. Standard of BS Control • Nephropathy • Ischemic heart disease, CHF and Cardiomyopathy • Autonomic neuropathy • Retinopathy • Stiff joint syndrome • Electrolyte & metabolic derangement

30. Standard of BS Control • Nephropathy • Ischemic heart disease, CHF and Cardiomyopathy • Autonomic neuropathy • Retinopathy • Stiff joint syndrome • Electrolyte & metabolic derangement

32. Standard of BS Control • Nephropathy • Ischemic heart disease, CHF and Cardiomyopathy • Autonomic neuropathy • Retinopathy • Stiff joint syndrome • Electrolyte & metabolic derangement

34. Standard of BS Control • Nephropathy • Ischemic heart disease, CHF and Cardiomyopathy • Autonomic neuropathy • Retinopathy • Stiff joint syndrome • Electrolyte & metabolic derangement

36. Case 1 • 60 year old, 60 kg man, height 165 cm; scheduled for abdominoperineal resection of Ca. rectum • Known diabetic on Metformin and Glibenclimide, BD dose • Hypertension, CAD under check • BG: (F) = 120, (PP) = 170 mg.dl-1 Switch over to insulin pre-op? Pre-op orders?

37. Case 1 • 60 year old, 60 kg man, height 165 cm; scheduled for abdominoperineal resection of Ca. rectum • Known diabetic on Metformin and Glibenclimide, BD dose • Hypertension, CAD under check • BG: (F) = 120, (PP) = 170 mg.dl-1 • Morning BG=90; ½ h intra-op=150 Intra-op fluids and insulin?

43. Patient’s Forearm Patient’s Forearm NO INFUSION PUMP AVAILABLE INFUSION PUMP AVAILABLE N-Saline / Colloid / Blood N-Saline / Colloid / Blood as required D-5 (500 mL) + K+ 10mmol @ G=0.1g/kg/h D-5 (500 mL) + K+ 10mmol N-Saline (500 mL) + 8U insulin Infusion Pump Insulin (1U/60mL) Insulin (1U/mL)

44. Vellore regimen?

45. Miriam A and Korula G.A Simple Glucose Insulin Regimen for Perioperative Blood Glucose Control: The Vellore Regimen. Anesth Analg 2004;99:598-602 • Intraoperative blood glucose control with 1 U of insulin for every 1–50 mg of blood glucose value more than 100 mg/dL added to 100 mL of 5% dextrose in a measured volume set • Hourly monitoring of blood glucose • Blood glucose control was compared with the different existing techniques followed in the hospital • The study group had a mean ± SD blood glucose value of 156 ± 36 mg/dL, and the control group’s value was 189 ± 63 mg/dL (P = 0.003) • Poorly controlled patients (<100 & >200-mg/dL) decreased from 51% to 28% (no patient less than 60 mg/dL) compared with the control group in which it increased from 49% to 72% (10 patients less than 60 mg/dL) (P = 0.0013) • It is a simple and effective method and combines the advantages of combined glucose insulin and variable rate insulin infusion

46. Ringer’s lactate? • Bank blood?

47. Fluid and volume replacement • Lactate and is a gluconeogenic substrate • Ringer’s lactate = 28 meq/L • Bank blood = variable amounts (anaerobic metabolism during storage) • Hepatic conversion to glucose  aggravation of stress-induced hyperglycemia • Ringer’s lactate/Blood are NOT contraindicated but inappropriate as these can confound the calculation of glucose load and insulin requirements somewhat

48. Case 1 • 60 year old, 60 kg man, height 165 cm; scheduled for abdominoperineal resection of Ca. rectum • Known diabetic on Metformin and Glibenclimide, BD dose • Hypertension, CAD under check • BG: (F) = 120, (PP) = 170 mg.dl-1 • Morning BG=90; ½ h intra-op=150 Epidural + GA planned; Considerations during CN Blockade?

49. Regional blocks • LA requirements lower • Risks of nerve injury higher • Combination of LA with epinephrine may pose greater risk of ischemic or edematous nerve injury (or both) in diabetic • Document peripheral neuropathy • keeps the patients and relatives informed • avoids medico-legal hassles later on • Insulin response to hyperglycemia • high thoracic (T1-T6) blockade  ?inhibited • low blockade, (T9 - T12)  no effect

50. Case 2 • 40 year old, 45 kg lady • Known diabetic on oral antihyperglycemics • High grade fever x 1wk, vomiting x till 2 days back, altered sensorium x 12 h • P=180 bpm, BP=70/40, BG=470 mg.dl-1, • Blood Ketones (+++), pH=6.8, Na+-116, K+- 3.4, HCO3-10, PCO2- 34, PO2- 78 mmHg • Emergency laparotomy • Yes/No? How quickly? What till then?