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DM : Perioperative glycaemia control

DM : Perioperative glycaemia control. Moderators : Prof Chandralekha/ Dr Chhavi Presenter : Ranju Gandhi. www.anaesthesia.co.in anaesthesia.co.in@gmail.com. Aggressive control of intraoperative blood glucose concentration A shifting Paradigm? Anesthesiology 2005;103.

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DM : Perioperative glycaemia control

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  1. DM : Perioperative glycaemia control Moderators : Prof Chandralekha/ Dr Chhavi Presenter : Ranju Gandhi www.anaesthesia.co.inanaesthesia.co.in@gmail.com

  2. Aggressive control of intraoperative blood glucose concentrationA shifting Paradigm?Anesthesiology 2005;103 Poor intraoperative blood glucose control is associated with a worsened hospital outcome after cardiac surgery in diabetic patients. (Outarra et al) Anesthesiology 2005;103

  3. Immediate periop problems in a diabetic • Surgical induction of stress response • Interruption of food intake • Altered consciousness masks symptoms of hypoglycemia & necessiate frequent BG estimations • Circulatory disturbances associated anaesthesia & Sx

  4. Perioperative glycaemia control • Goal : 120-200 mg/dl, normal metabolism • Metabolic effects of surgery ↑Stress hormones ↓Carbohydrate ↑Cortisol,glucagon,GH ↑Insulin ↑Epinephrine ↓Insulin ↑Resistance to insulin Hyperglycemia------------------------------- Hypoglycemia Glycemia

  5. Perioperative complications with Hyperglycemia • Dehydration, electrolyte & metabolic disturbances • Predisposes to DKA • Delayed wound healing • Bacterial infection & postop wound infection • Median glycemic threshold for neutrophil dysfunction 200 mg/dl

  6. Perioperative complications with Hyperglycemia (cont) • Independent risk factor for increase in short & long term mortality after cardiovascular surgery • Worsens clinical outcome in nonlacunar (atheroembolic) stroke, traumatic brain injury, global & focal cerebral ischaemia • Haemorrhagic extension of ischaemic stroke

  7. Benefits of normal blood glucose • Maintenance of normal white blood cell & macrophage function • Positive trophic & anabolic effects of insulin • Improved erythropoiesis • Decreased hemolysis • Reduced cholestasis • Less axonal dysfunction

  8. Hypoglycemia • BG 45-50 mg% • Sympathoadrenal (BG ↓es rapidly) Weakness, sweating, ↑ HR, palpitations, tremor, nervousness, irritability, tingling, hunger • Neuroglycopenia (BG constantly low) Headache, ↓ temp, visual disturbances, mental confusion, amnesia, seizures, coma Treatment : Unconscious : 100 ml 25 % D iv or Glucagon im/sc

  9. Factors considered in selecting a regimen for glycemic control • Type of DM • How aggressively euglycemia sought • Whether patient takes insulin • Surgery minor & in an ambulatory unit • Surgery elective or emergency • Ability of hospital resources

  10. Traditional Regimens Χ“No glucose, no insulin” Limitations : • Not suitable for insulin dependent diabetics • Pt’s stores of glucose used to meet increased metabolic demands • Patients taking long acting OHAs predisposed to hypoglycemia Acceptable for non-insulin dependent diabetics & minor surgical procedures Frequent blood sugar monitoring. May require insulin therapy

  11. “Non tight control” regimen Aim : Prevent hypoglycemia, ketoacidosis, hyperosmolar states Day before surgery : NPO > midnight Day of surgery : iv 5%D @1.5 ml/kg/hr(Preop + intraop) Subcut one half usual daily intermediate acting insulin on morning of surgery, increased by 0.5U for each unit of regular insulin dose of insulin subcut Postop : Monitor blood glu & treat on sliding scale

  12. “Non tight control” regimen • Limitations: • Insulin requirements vary in periop period • Onset & peak effect may not corelate with glu cose admn or start of surgery • Hypoglycemia esp in afternoon • Lowest therapeutic ratio

  13. Tight control regimen I • Aim : 79-120 mg/dl • Protocol • Evening before, do preprandial bld glucose • Begin iv 5%D @ 50 ml/hr/70 kg • Piggyback to 5%D, infusion of regular insulin (50 U in 250 ml 0.9% NS) • Insulin infusion rate (U/hr) plasma glu (mg/dl) / 150 or /100 if on steroids or severe infection • Repeat bld glu every 4 hours • Day of surgery : Non dextrose containing solutions, • Monitor blood glu at start & every 1-2 hours

  14. Tight control regimen II • Aim : Same as TC regimen I • Protocol : Obtain a feedback mechanical pancreas & set controls for desired plasma glucose. • Institute 2 iv drips for insulin & fluids

  15. Alberti’s regimen • 1979- Alberti & Thomas IV GIK solution [500ml 10% glucose + 10 units soluble insulin + 1 gm KCl @ 100 ml/hr] • Before surgery - stablize on soluble insulin regimen, omit morning dose of insulin • Commence infusion early on morning & monitor glu at 2-3 hours • < 90mg/dl or > 180 mg/dl replace bag with 5U or 15U respectively

  16. Alberti’s regimen-Recent version • Initial solution : 500ml 10% glu + 10 mmol KCl + 15 U Insulin, infuse at 100 ml/hr • Check Blood glu every 2 hours • Adjust in 5 U steps • Discontinue if bld glu < 90 mg/dl

  17. Alberti’s regimen • Advantages : simple, Inherent safety factor, balance appropriate • Criticism : hypoglycemia, water load & hyponatremia, cautious : poor renal function • 20% or 50% D

  18. Hirsh regimen • Aim : Normoglycemia • Infuse glucose 5 g/hr with pot 2-4 mmol/hr • Start insulin infusion @.5-1U/hr • Measure blood glucose hourly

  19. Regular Insulin Sliding Scale • RECOMMENDATIONS • Supplement usual diabetes medications to treat uncontrolled high blood sugars • Short term use (24-48 h) in a patient admitted with unknown insulin requirement • Should not be used as a sole substitute, risk of DKA Periop changes in regional blood flow – unpredictable absorption

  20. Regular Insulin Sliding Scale

  21. Split-mixed insulin regimen • Combining multiple daily injections of intermediate or long acting insulin ( NPH, lente, or ultralente) rapid or short acting insulins (Regular,insulin lispro, or insulin aspart) • “1500 Rule” : (ICF) 1500/total insulin dose equals how much 1 unit of regular insulin will decrease blood glucose.

  22. Intraoperative glucose control • Subcut insulin not advised – potentially erratic absorption secondary to altered regional blood flow, tissue edema, or fluid shifts during Sx • Iv bolus of insulin : very short half life (8 min), dangerous iatrogenic hypokalemia, hypophosphatemia, hypomagnesimia, hypoglycemia • Iv insulin infusion preferred • Adsorption of onto surface of syringes, iv fluid bags & iv sets - unavoidable problem. Flush line & discard - saturates insulin binding sites of tubing

  23. Insulin pumps • Continuously administer insulin preprations (short acting) through a subcutaneous catheter • Programmed to have variable output throughout day, night & can administer bolus • Options : Turn off & use a continuous insulin infusion or continue pump at a basal rate supplemented with dextrose & K with rate adjustment based on serial BG measurement

  24. Diabetes & Glucocorticoid therapy- Steroid diabetes • Minimal elevation of fasting bld glucose • Exaggeration of postprandial hyperglycemia • Insensitivity to exogenous insulin • Preexisting diabetics-profound hyperglycemia • Variable rate insulin infusion appropriate mode of therapy

  25. Anaesthesia technique for diabetic patients • Depends on existing end organ pathology • Regional anaesthesia : • Pt with AN: Profound hypotension with coexisting coronary artery, cerebrovascular or renovascular d/s • Increased risk of infection- epidural abscess & vascular damage • Peripheral neuropathy presenting later may be confused with anaesthetic complication • At present no evidence alone or in combination with GA confer any benefit in terms of mortality & major complications

  26. Potential benefits of regional anaesthesia in diabetics: • Avoidance of tracheal intubation (stiff joint snndrome, gastroparesis) • Decreasing venous thromboembolism • Ophthalmic Sx : More rapid recovery, earlier mobilization, better pain relief, less NV & earlier oral intake • Abolishes catabolic hormonal response to surgery • Preferable to use specific nerve blocks over CNB • Can report symptoms of hypoglycemia

  27. Effect of anaesthetics • Etomidate : ↓ glycemic response to Sx • Midazolam : At high doses, ↓es ACTH/cortisol secretion, stimulates GH secretion, net effect ↓ glycemic response to Sx • Clonidine : Improved glycemic control (↓ed sympathoadrenal activity), ↓ insulin secretion • Volatile agents(halothane, isoflurane) : Θ glucose stimulated insulin secretion in a dose dependent manner

  28. General anaesthesia in a diabetic • Antiaspiration prophylaxis • Stiff joint syndrome + AN : Awake FOI • AN : Aim is haemodynamic stability • IBP : Monitor BP lability • Adequate analgesia • AN : Aggressive intraop measures to maintain normothermia

  29. Periop management : Type II Diabetics

  30. Oral hypoglycemic agents • Sulfonylureas – Long acting discontinued 48-72 hours before surgery, Short acting held night before or morning of surgery • Thiazolidinediones : Rosiglitazone, piaglitazone omitted on morning of Sx • Biguanides : Metformin discontinued atleast 24 h prior to Sx & held for 48 h after major Sx • Alpha-glucosidase inhibitors (acarbose, miglitol) have no effect on fasting blood glucose

  31. Patient on diet control or OHA

  32. Periop management : Type II Diabetics • Poorly controlled preop (>200 mg%) or even if well controlled on OHA undergoing major surgery : Shift to plain insulin preoperatively • Well controlled Type II taking insulin : Treat as type I

  33. Type I DM or Type II DM on insulin

  34. Emergency surgery • Fast correction of dehydration, hyperosmolarity, ketoacidosis & electrolyte imbalance • Severe hyperglycemia treated by one or more iv bolus of 5U insulin : ↓ BG < 200 mg% • Infection : Glycemic control elusive until cause treated

  35. Tighter glycemic control (<110 mg%) • Aortocoronary bypass • Surgery with interruption of cerebral blood flow • Obstetrics • Critically ill patients (reduction of mortality by 34%, blood stream infections by 46%, ARF requiring dialysis by 41%, critical illness neuropathy by 44% & less likely requirement for prolonged mechanical ventilation & intensive care)

  36. GDM • State of relative insulin resistance (↑Estrogen, progesterone, cortisol, HPL, TNF α ) • 10 area of expression : β subunit of insulin receptors & insulin receptor substrate 1 • Diminished tyrosine kinase activity at cell mem level • Exaggerated, pathological level of normal physiological adaptations

  37. Maternal implications • 2-3 fold ↑ risk of preeclampsia • Delivery by CS • UTI & subsequent pyelonephritis • Ketoacidosis & hyperglycemic crisis • 50% risk of type 2 DM within 20 years

  38. Fetal implications • Fetal growth disorder & still birth • Still birth – after 36 weeks, ↑ : poor glycemic control on insulin & pregnancy complicated by polyhydramnios & preeclampsia • Mech : Chronic fetal hypoxia, ↑ fetal metabolic rate, O2 consumption & RBC deoxygenation • Macrosomia : Birth wt > 4-4.5 kg or > 90 th percentile, 50 % pregnancies with GDM – Shoulder dystocia • RDS, cardiac septal hypertrophy, persistent fetal circulation, polycythemia & hyperbilirubinemia • Neonatal hypoglycemia • Long term complications : obesity & type 2 DM later life

  39. Diagnosis • Screening test : At prenatal visit, repeated at 24-28 week – 50 g oral glucose challenge, Plasma glu > 130 mg % cut off ( fasting not required) • +ve- 3 hr OGTT • GDM- ≥ 2 abn values

  40. Diagnostic criteria for GDM • Fourth international workshop-conference on GDM recommended Carpenter-Coustan criteria • Classified into A1 & A 2 • A1 : Normal FBS & adequate control with diet alone • A 2 : Elevated fasting or 2 hr PP requiring insulin

  41. Glucoregulation:Labor & Delivery

  42. IDDM for CS –Glycemic management • Usual dose of insulin night before surgery • Withold insulin on morning of surgery • Measure FBS; if > 120, delay surgery, start 5%D @2.55mg/kg/min & insulin @ 1-5u/hr; adjust dose to maintain plasma glu 70-120 mg%, delay surgery until euglycemia maintained for 4 hours • FBS<120 mg%, give no insulin & start IVF without dextrose • ↓ insulin dose to 60% of antepartum dose in postop period with hourly plasma glu monitor

  43. IDDM for CS –Glycemic management • Measure FBS on morning of surgery • Start 5%D with insulin & infuse @ 1-2 U/hr & glucose @ 150 mg/kg/hr; adjust the dose of insulin & glu per hourly to maintain 70-120 mg% • Measure BG each hour • If glu levels > 120 mg %, treat with a bolus of 1 unit of insulin & increase infusion • If glu < 70 mg%, administer 2-5 g of glucose

  44. Conclusion • Diabetics at greater risk of periop mortality & morbidity after major surgery • Improving glycemic control in both short & long term improves outcome • In future, islet cell transplant, artificial pancreas, recently modified insulin ( Lispro, Glargine), constant infusion techniques will have a greater role. • Appropriate metabolic control in periop period is imperative & is a attainable goal

  45. www.anaesthesia.co.inanaesthesia.co.in@gmail.com

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