Case Presentation: Diabetes Mellitus

1. Case Presentation:Diabetes Mellitus Moderator: Dr. RENU Presenter: Dr. DIPAL www.anaesthesia.co.inanaesthesia.co.in@gmail.com

2. History: • Din dayal: 52y/M, 60 kg Chief Complaints: • Pain in the Rt Lower Limb since 1 wk • Bluish black discoloration of Rt foot since 2 days

3. History: • K/C/O DM • Apparently alright 1 wk back • H/O trivial trauma to the Rt toe • Pain and ulceration at site of injury • Purulent foul smelling discharge • Noticed bluish black discoloration of the great toe since two days progressed to involve entire Rt foot • No H/o fever, swelling of lower limb

4. History • DM since 15 years on irregular treatment with OHA • Since 2 days: insulin sliding scale • poorly controlled • H/o dizziness with sweating episode , weakness 10 days back, relieved on taking food • H/o tingling and numbness in both lower limbs since 2 yrs • H/o frequent change of spectacles

5. History: • H/o similar discoloration in Lt great toe 2 yrs back, amputation done ↓ RA, U/E No H/o: • Chest pain, palpitations, breathlessness, orthopnea/ PND, edema feet, syncope, cough • ↓ urine output, generalized edema • Giddiness on change of posture • Effort tolerance limited due to pain , • Initially could climb 3 flights of stairs

6. History: • Htn since 16 yrs on treatment with T. Amlodipine 5 mg od • No H/O Asthma, convulsions, TB, any other major medical illness • No H/O Drug allergy

7. Personal history: • Bowel and bladder habits: no complaints • Alcoholic: occasional • Cigarette smoker: smoked for 30 yrs, left since 2 yrs, 15 pack years.

8. Treatment history: • Inj. Piperacillin and Tazobactum 4.5g i.v. 8th hrly • Inj. Levoflox 500 mg i.v. od • Inj. Metrogyl 500mg 8th hrly • T. Amlodipine 5 mg od • T. Hydroclorthiazide 50 mg od • T. Atorvastatin 10 mg od • T. Aspirin 150 mg od • Inj. Insulin Sliding Scale

9. General Examination • Wt: 60 kg, ht: 164 cm • Conscious, Oriented • Pulse: 80/min, Rt radial, regular, adequate volume, Rt dorsalis pedis not felt, all other peripheral pulses well felt • Bp: 110/ 70 mm of Hg supine position, 108/ 70 mm of Hg sitting position. • RR: 22/ min, regular • HR response to deep breathing: > 15bpm

10. General Examination: • Afebrile • No pallor, icterus, cyanosis, clubbing, jaundice, lymphadenopathy • JVP: not raised • Good i.v. access

11. Systemic Examination: • CVS: apex beat in 5th intercoastal space ant axillary line S1, S2 heard, no murmurs • RS: B/L air entry present No crepitations or rhonchi • PA: soft, no organomegaly • Spine: spaces well felt

12. Systemic Examination: • CNS: higher functions normal • Sensory examination: B/L Superficial: pain, touch and temperature sensation were decreased in the distal parts Deep: pressure , position sense and vibration sense intact and normal in both the limbs . • Motor examination: B /L Power and tone: normal in both the limbs Reflexes: Ankle jerk: B/L absent . all other reflex present

13. Airway examination: • Mouth opening: 5 cm • MMP class: 2 • Neck movements: WNL • TMD: 6 cm • Teeth: intact • Prayers sign: negative

14. Local examination: • Rt lower limb: 4x6 cm ulcer, on great toe, blackish discoloration till ankle, no line of demarcation, purulent discharge, foul smelling Surrounding skin: tender, swollen, erythematous Dorsalis pedis absent, all other pulses well felt Thinning of skin, sparseness of hair till knee • Lt lower limb: WNL

15. Investigations: FBS: 145 mg/dl Urine sugar: -ve Urine ketones: -ve ECG: normal sinus rhythm No ST- T wave changes X-ray chest: Cardiomegaly Rest NAD • Hb: 9.8 • Hct: 30.7% • Plt ct: 3 lakh • Tlc: 16100 • Dlc: 88/ 10/ 02 • Urea: 51 • Creatinie: 1.2 • Na/ K: 137/ 5.1 • T. Bili: 0.6 • TP/ A/G: 7.5/ 3.3/ 4.2 • SGOT/SGPT: 49/ 72 • Alk Po4: 244

16. Investigations: • ABG: • pH: 7.314 • pO2: 92.0 • pCO2: 37.8 • HCO3: 26.5 • BE: -3.0

17. Provisional Diagnosis: • Gangrene of Rt foot with diabetes mellitus with hypertension

18. Surgery planned: • Rt below knee amputation

20. Anesthesia: • Preoperative: • NPO • Consent • Medications: insulin, GIK, others • Procedure • Investigations: BS

21. Anesthesia: • Plan: SAB • OT preparation • Drugs • Monitoring • Fluids • SAB

23. Revised diagnostic criteria for diabetes mellitus

24. Diabetic dysautonomic neuropathyscoring

25. Diabetic dysautonomic neuropathy scoring

26. Insulin preparations and guidelines

27. Insulin preparations and guidelines

28. Insulin preparations and guidelines

29. Insulin preparations and guidelines

30. Oral Hypoglycemic Agents

31. Oral Hypoglycemic Agents

32. Oral Hypoglycemic Agents

33. 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

34. “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

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

36. Tight control regimen I • Aim : 79-120 mg/dl • Protocol • Evening before, do pre-prandial 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

37. 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

38. Alberti’s regimen • 1979- Alberti & Thomas IV GIK solution [500ml 10% glucose + 10 units soluble insulin + 1 gm KCl @ 100 ml/hr] • Before surgery - stabilize 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

39. 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

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

41. 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

42. 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

43. Regular Insulin Sliding Scale

44. 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.

45. Patient on diet control or OHA

46. 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

47. Type I DM or Type II DM on insulin