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Pre –operative Evaluation in Diabetes , Thyroid Diseases

Pre –operative Evaluation in Diabetes , Thyroid Diseases. Haddadi S MD Guilan University of Medical Sciences. Diabetes Mellitus. Accidental BS >200 mg/dl FBS >126 mg/dl GTT > 200 mg/dl. Pre-op in diabetics patients :.

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Pre –operative Evaluation in Diabetes , Thyroid Diseases

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  1. Pre –operative Evaluation in Diabetes , Thyroid Diseases Haddadi S MD Guilan University of Medical Sciences

  2. Diabetes Mellitus • Accidental BS >200 mg/dl • FBS >126 mg/dl • GTT > 200 mg/dl

  3. Pre-op in diabetics patients : • Diabetics are at risk for multi organ dysfunction , with renal insufficiency , stroke , peripheral neuropathy , autonomic dysfunction ,cardiovascular disease , delayed gastric emptying , retinopathy ,reduced joint mobility • CAD equivalent • Autonomic neuropathy is the best predictor of silent ischemia • Poorly controlled BS ,longer duration of disease correlate with cardiac risk ,increased risk for heart failure

  4. Heart failure is twice in men , 5 times as common in women with DM as in non-DM • Increased risk for renal failure peri -operatively , post –op infections • Poorly controlled diabetic patients are at risk for the development of stiff joint syndrome with reduced cervical mobility

  5. Waxy edema • Non pitting edema in neck ,back of neck • Diabetic scleroderma • Gastroparesia ,risk of aspiration (NPO)

  6. Pre op evaluation: • Assessing organ damage • Control of BS • CVS ,renal ,neurologic systems ,musculo skeletal (non-enzymatic glycozilation in proteins ,abnormal connections in collagen)

  7. Pre-op ECG • Electrolytes • BUN , Creatinine • BS • Patients with autonomic neuropathy , risk of silent ischemia stress test

  8. In renal disease ,control of HTN • Hydration status • Avoiding from nephrotoxic drugs • Autonomic neuropathy ,peri- op cardiac dysrhythmia , hypotension • Patients with autonomic dysfunction or hypovolemia will have greater than a 20 mmHg drop in SBP ,10 mmHg drop in DBP when assuming upright position from recumbence

  9. Goals of peri-op diabetic management: • Avoidance of hypoglycemia • Avoidance of marked hyperglycemia • Target FBS <110 mg/dl in non critically ill hospitalized patients

  10. 2/3 NPH ,Regular nocturnal dosage (pre-op) • ½ NPH morning dosage • Pump : reducing the infusion speed 30% • 2/3 Glarigin nocturnal dose(pre-op) ,elimination diurnal dose • Ablation oral hypoglycemic drugs from 24-48 hours pre operatively (Sulfonilurease)

  11. Pre op evaluation in Thyroid disorders: • Pre –op euthyroid state • Mild to moderate dysfunction probably has minimal impact peri-op • Significant hyper , hypothyroidism appears to increase peri-op risk • Amiodarone ⇨risk for hypothyroidism, TFT before surgery

  12. Patients with a history of chronic thyroid disease need TFT before surgery • If symptomatology ,therapy have not changed ,tests within 6 months before surgery are adequate • TSH are best to evaluate for hypothyroidism • Free T3,T4, TSH is useful in hyperthyroid state

  13. Elective surgery should be postponed until patients are euthyroid • Pre-op consultation with an endocrinologist ,if surgery is urgent in patients with clinical thyroid dysfunction • Continuation of thyroid replacement medications & antithyroid drugs such as PTU on the day of surgery

  14. TFT • Upper airway evaluation ( CXR,CT scan) • Eye protection • Decreased gastric emptying in hypothyroidism (regurgitation) • Vocal cord edema , large goiter • ⇩CO (S.V.,HR ,Baroreceptor reflex) • ⇩responsiveness to hypoxia ,hypercarbia • Risk of hypothermia • Platelet dysfunction , ⇩factor 8,Na,Glc

  15. Angina is unusual in hypothyroidism • Thyroid hormone replacement • IHD ,coronary angiography ,CABG

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