การให้ยาระงับความรู้สึกในผู้ป่วยโรคเบาหวานและโรคต่อมไทรอยด์

1. การให้ยาระงับความรู้สึกในผู้ป่วยโรคเบาหวานและโรคต่อมไทรอยด์การให้ยาระงับความรู้สึกในผู้ป่วยโรคเบาหวานและโรคต่อมไทรอยด์ พญ.รัตนาภรณ์ บุริมสิทธิชัย ภาควิชาวิสัญญีวิทยา โรงพยาบาลจุฬาลงกรณ์

2. การให้ยาระงับความรู้สึกในผู้ป่วยโรคเบาหวานการให้ยาระงับความรู้สึกในผู้ป่วยโรคเบาหวาน

3. Criteria for the diagnosis of DM • FPG ≥126 mg/dl (NPO at least 8 h) or • Symptoms of hyperglycemia (polyuria, polydipsia and unexplained weight loss) and a casual plasma glucose ≥200 mg/dl (any time) or • 2-h plasma glucose ≥200 mg/dl during an OGTT Repeat testing on a different day

5. Impaired fasting glucose (IFG)Impaired glucose tolerance (IGT) • Fasting plasma glucose levels ≥100 mg/dl but <126mg/dl or • 2-h values in the OGTT of ≥140 mg/dl but <200 mg/dl • Pre-diabetes • Associate with the metabolic syndrome : obesity, dyslipidemia and hypertension

6. Metabolic abnormality • Hyperglycemia • Osmotic diuresis, dehydration, electrolyte imbalance • Lipolysis • Increased serum free fatty acid, ketone • Increased low density lipoproteins • Protein breakdown • Stress • cortisol, glucagon, catecholamine, growth hormone

7. Classification of DM • Type 1 • Destruction of pancreatic βcells (autoimmune) • Absolute insulin deficiency and requirement • Type 2 • Variable degrees of insulin deficiency and resistance • Diet control, oral hypoglycemic drugs, insulin • Other • Steroid • Gestational diabetes

8. Common insulin preparations

9. Common preparations of oral hypoglycemic drugs

10. Complications of DM • Acute complications • Hypoglycemia • Diabetic ketoacidosis (DKA) • Hyperosmolar nonketotic coma • Chronic complications • Macrovascular : atherosclerosis • Microvascular : diabetic retinopathy, nephropathy, neuropathy

11. Hypoglycemia • Glucose level < 50 mg/dl • Fasting, long-acting insulin/OHD, renal insufficiency • Altered mental status, coma and seizure • Physiologic responses to catecholamines • Diabetic patient may be symptomatic at higher glucose level • Anesthetized patient, beta blocker • 50 ml of 50% glucose IV

12. Diabetic ketoacidosis (DKA) • Type 1 DM • Metabolism of free fatty acid • Glucose 300-500 mg/dl, increased anion gap metabolic acidosis • Dehydration, osmotic diuresis, Kussmaul breathing, fruity breath, nausea and vomiting, abdominal pain, ileus, leukocytosis and elevated amylase level • Precipitating factors : infection, surgical stress, trauma, lack of insulin therapy

13. Management of diabetic ketoacidosis • Identify and treat precipitating causes • RI 10 unit IV bolus followed by an infusion at blood glucose/150 unit/hr • NSS infusion : vital signs and urine output • Potassium replacement when urine output > 0.5 ml/kg/hr • Add 5%dextrose infusion when glucose decreased to 250 mg/dl • Serial glucose and electrolyte level • Hemodynamic monitoring

14. Hyperosmolar nonketotic coma • Type 2 DM under stress • Glucose level > 600 mg/dl • Profound dehydration, confusion, coma and seizures • Intravascular thrombosis • Volume resuscitation : NSS • Rapid correction of hyperosmolarity leading to cerebral edema

15. Preoperative evaluation • Preoperative glucose level control • Fasting blood glucose • HbA1c < 7 mg/dl • End organ dysfunction • Atherosclerosis • Coronary artery disease : myocardial ischemia/infarction • Cardiomyopathy • Peripheral vascular disease • Cerebrovascular disease

16. End organ dysfunction • Diabetes nephropathy • 40-50% of DM patients • Albuminuria • ACEIs, ARB • Diabetic retinopathy • Diabetic stiff joint syndrome • 40% in DM type1 • Difficult laryngoscopy : decrease mobility of atlanto-occipital and tempero-mandibular joint • Prayer sign • Peripheral neuropathy:pressure injury

17. End organ dysfunction • Diabetic autonomic neuropathy • ANS reflex dysfunction • Old age, DM > 10 year, CAD and beta-blocker • Limited compensation for intravascular volume changes • Predispose to cardiovascular instability • Exaggerated pressor response to tracheal intubation • Postinduction hypotension • Sudden cardiac death • Intraoperative hypothermia

18. Clinical signs of diabetic autonomic neuropathy • Hypertension • Silent myocardial ischemia/infarction • Orthostatic hypotension • Lack of HR variability • Reduced HR response to atropine and propranolol • Resting tachycardia • Gastroparesis • Neurogenic bladder • Lack of sweating • Impotence

19. Anesthetic management • Avoid hypoglycemia • Signs and symptoms of hypoglycemia will be masked by GA, beta-blocker • RA and peripheral nerve block • Monitoring • Blood glucose • Invasive monitoring • NPH vs protamine sulfate • Severe bradycardia : epinephrine

20. Perioperativeglycemic control • Anesthetic agents : modulation of SNS • Association between hyperglycemia and increased morbidity and mortality • Type, severity of DM and extent of surgery • Hold short acting agents on the day of surgery, long acting agents 2-3 days prior • Cardiopulmonary bypass, pregnancy, neurological surgery • Goal 80-110 mg/dl

21. Perioperative insulin regimen • Bolus administration • ½ of the usual intermediate-acting insulin subcutaneously on the morning • Regular insulin 1 unit reduce blood glucose 30 mg/dl • Insulin infusion • Separate IV line • Regular insulin 10 unit in NSS 100 ml (1u/h=10ml/h) • Blood glucose/150 = insulin unit/h 5%dextrose infusion 80-120 ml/h Serial blood glucose every 1-2 h

22. Postoperative management • Continue glucose level control • Osmotic diuresis • Infection • Poor wound healing • Lactate-containing fluid • Rising in blood glucose level 24-48 hr postoperatively

23. การให้ยาระงับความรู้สึกในผู้ป่วยโรคต่อมไทรอยด์การให้ยาระงับความรู้สึกในผู้ป่วยโรคต่อมไทรอยด์

25. Thyroid function test • Total serum triiodothyronine (T3) and thyroxine (T4) • Free T3 and T4 • Thyroid hormone binding rate (THBR) • Thyroid stimulating hormone (TSH) Normal plasma T4 5-12 mcg/dl Normal plasma T3 80-220 ng/dl Normal THBR 30-40% Normal TSH 8 µIU/ml

26. Test of thyroid gland function

27. Hyperthyroidism

28. Hyperthyroidism Pituitary tumor Grave’s disease Thyroid adenoma Toxic multinodular goiter Thyroiditis Iatrogenic Exogenous iodide

29. Manifestations of hyperthyroidism • Weight loss, diarrhea, skeletal muscle weakness, hyperactive reflexes, warm and moist skin, heat intolerance, diaphoresis, nervousness • Tachycardia, high CO, elevated SBP, decrease DBP, heart failure, atrial fibrillation • Aggravate myocardial ischemia • Increased beta receptor sensitivity

30. Manifestations of hyperthyroidism • Mild anemia, thrombocytopenia • Fine tremor, exophthalmos, goiter • Bone resorption and hypercalcemia

31. Hyperthyroidism • Treatment • Medical treatment • Antithyroid drugs : propylthiouracil, methimazole • Beta adrenergic blocking agent • Inorganic iodide • Corticosteroid • Radioactive iodine • Surgical treatment • Failed medical therapy, cancer, symptomatic goiter, cosmetic

32. Mechanism of action of antithyroid drugs

33. Preoperative evaluation • Euthyroid state before surgery • antithyroid drugs 6-8 wk • Controlled hyperdynamic CVS • resting heart rate < 90 bpm • Inorganic iodide : reduce size • Continue medications • Side effects of antithyroid drugs • Rash, fever, nausea, agranulocytosis, hepatitis, arthralgia, hypothyroidism

34. Preoperative evaluation • Emergency surgery • Esmolol 100-300 mcg/kg/min • Dexamethasone 8-12 mg/d • Airway obstruction • Substernal goiter • X-ray neck • CT • Premedication • Benzodiazepine • Anticholinergic

35. Tracheal comprssion

36. Tracheal compression

37. Anesthetic management • Regional anesthesia • General anesthesia • Adequate depth of anesthesia • Reinforced ETT • Avoid meds that stimulate SNS • Ketamine, pacuronium, indirect-acting vasopressor • Thiopental : antithyroid activity

38. Anesthetic management • Chronic hypovolemia and vasodilation • Exaggerated hypotension postinduction • Unchanged MAC • Eyes protection • Maintain body temperature • Myasthenia gravis

39. Thyrotoxic crisis (Thyroid storm) • Undiagnosed/uncontrolled hyperthyroid with surgical stress or illness • 6-18 hr postoperative • Tachycardia, dysrhythmia, CHF, MI, dehydration, shock, hyperthermia, agitation • Differential diagnosis • Pheochromocytoma • Malignant hyperthemia • Neuroleptic malignant syndrome • Light anesthesia

40. Treatment of thyrotoxic crisis • Precipitating causes • Cooled crystalloid solution • Sodium iodide 250 mg PO or IV q 6 h • PTU 200-400 mg PO or NGT q 6 h • Hydrocortisone 50-100 mg IV q 6 h • Propranolol 10-40 mg PO q 4-6 h or 1-2 mg IV or esmolol infusion 50-100 mcg/kg/min • Cooling blanket, acetaminophen and meperidine 25-50 mg IV q 4-6 h to prevent shivering • Digoxin if AF with RVR

41. Post-thyroidectomy complication • Recurrent laryngeal nerve injury • Unilateral • bilateral • Tracheal compression • Hematoma • Tracheomalacia • Hypoparathyroidism • Hypocalcemia 24-72 h postoperatively • Inspiratory stridor, laryngospasm

42. Hypothyroidism

43. Hypothyroidism • Etiology • Primary hypothyroidism • Thyroid gland dysfunction : Hashimoto’s thyroiditis, previous subtotal thyroidectomy, RIA, irradiation of the neck • Thyroid hormone deficiency : antithyroid drugs, dietary iodine deficiency • Secondary hypothyroidism • Hypothalamic dysfunction • Anterior pituitary dysfunction

44. Clinical manifestations • Reduction in metabolic activity • Weight gain, lethargy, slow mental functioning, cold intolerance, slow movement • Cardiovascular • Bradycardia, decreased contractility, CO • Increased SVR, diastolic hypertension • Pericardial fluid • Angina pectoris, CHF

45. Clinical manifestations • Respiratory • Depressed ventilatory responsiveness to hypoxia and hypercarbia, pleural effusion • Sleep apnea • Renal • Decreased renal blood flow, hyponatremia • Anemia, coagulopathy • Delayed gastric emptying, constipation

46. Clinical manifestations • Hypothermia • Cool, dry and mottled extremities • Blunted stress response and adrenal depression • Dull facial expression, depression

47. Myxedema coma • Stupor or coma, hypoventilation, hypothermia, hypotension, hyponatremia • Mortality 25-50% • Infection, surgery, trauma • Life-threatening surgery • IV thyroid hormone • Precipitate myocardial ischemia • Acute primary adrenal insufficiency • Stress dose hydrocortisone

48. Management of myxedema • Tracheal intubation & controlled ventilation • Levothyroxine 200-300 mcg IV over 5-10 min then 100 mcg IV q 24 h • Hydrocortisone 100 mg IV then 25 mg IV q 6 h • Fluid and electrolyte therapy • Warming blanket

49. Preoperative evaluation • Postpone elective surgery in severe hypothyroidism (T4 < 1 mcg/dl) • Mild/moderate hypothyroidism • Preoperative thyroid hormone replacement vs ischemic heart disease • Difficult intubation : large tongue • Premedication • Sedative, thyroid hormone, steroid

50. Anesthetic considerations