Anaesthesia Diabetes notes .pptx,,to understand

Diabetic notes

1. Anaesthesia for Diabetic Patient Dr. Anila Malde Professor Anaesthesia , LTMMC & LTMGH, Sion , Mumbai

2. Diabetes Care Volume 39, Supplement 1, January 2016

3. Screening for DM All individuals >45 years At an earlier age Overweight (BMI) > 25 km/m 2 and One additional risk factor for diabetes

4. Risk factor for diabetes Family H/o diabetes (parent/ sibling with type 2 DM) Obesity (BMI 25 kg/m 2 ) Habitual physical inactivity Previously identified IFG or IGT H/o GDM or delivery of baby >4 kg (>9 lb) Hypertension (BP140/90 mmHg) HDL cholesterol <35 mg% &/or a triglyceride >250 mg% Polycystic ovary syndrome Acanthosis nigricans History of vascular disease

5. Chronic Complications of Diabetes Mellitus

6. Macrovascular

7. Microvascular

8. Others

9. Autonomic Neuropathy: S/S Orthostatic Hypotension Night blindness Nasal stuffiness History suggested gastro paresis Vomiting, Diarrhea, Abdominal distension Bladder atony Impotence Asymptomatic hypoglycemia

10. Critical Values of Bedside Autonomic tests suggestive of Autonomic Impairment Max-min R-R interval during forceful breathing <30msec <10bpm Valsalva ratio <1.2 SBP  during cold pressure test <10mmHg SBP  during standing >30mmHg DBP  during standing >10mmHg

11. Autonomic Neuropathy: Anaesthetic implications Prevent angina pectoris and thus obscure the presence of IHD Unexplained hypotension may be due to painless MI Shortening of the Q-T interval on the ECG  serious cardiac dysrhythmias HR response to atropine & propranolol is blunted Hypoglycemic unawareness

12. Autonomic Neuropathy: Anaesthetic implications Delayed gastric emptying Profound hypotension foll . neuraxial blockade Interference with control of breathing  more susceptible to depressant effects of drugs Unexpected cardiac or respiratory arrest

13. Cardiac Autonomic Neuropathy

14. Adverse CV consequences of Hyperglycemia Signal transduction ↓ K channel activation ↓ IPC ↓ APC Coronary μ circ ↓ dilatation in response to ischemia ↑ MvO 2 Endothelial Dysfunction ↓ endothelial dependent vasodilatation Biochemical Effects ↑ ROS ↑ AGEs ↓ NO Coronary collateral flow ↓ flow in existing vessels ↓ collateral development Coronary vasodilator reserve ↓ dilatation in response to vasodilators

15. Diabetic cardiomyopathy Normal systolic function

16. Decompensating Factors

17. Statins

18. Statin therapy  risk of Major cardiovascular events Death Hospitalization Continue statin preoperatively Statins if withheld → reinstitute at earliest in postop  

19. Anaesthetic Considerations in Diabetic Cardiomyopathy

20. Time course of development of diabetic nephropathy

21. Microangiopathy Renal Do estimation of eGFR Avoid Dehydration Hypotension Neprotoxic drugs

22. Microangiopathy Retinopathy Prevent sudden rises in BP that might rupture them, further damaging the eyesight Ensure adequate depth of anaesthesia , esp. at induction

23. Respiratory Diabetics, esp. if obese and smokers  prone to chest infections Optimize Chest condition

24. Stiff Joint Syndrome 30% to 40% of type I DM - limited joint mobility Initially small joints of the digits and hands Atlanto -occipital joint may be involved  difficulties in laryngoscopy Cause: Glycosylation of tissue proteins from chronic hyperglycemia

25. Gastrointestinal Autonomic neuropathy Delayed gastric emptying H 2 antagonist and metoclopramide as a premedication Rapid sequence induction with cricoid pressure, even for elective procedures

26. Optimize Co-morbidities

27. Anaesthetic Considerations: GA Choice of induction agent depends on overall condition Hypotension due to vasodilatation cannot be compensated by vasoconstriction  ↓ the dose & give slowly Etomidate More cardiostable Less hyperglycemia

28. Anaesthetic Considerations: GA Any volatile agent can be used as all have same effect on glucose homeostasis Gastroparesis Metoclopramide Rapid sequence induction Gastric tube

29. Anaesthetic Considerations: GA Avoid NSAIDs On aspirin→ haemorrhage Gastritis, diarrhoea → dehydration ↓ Renal blood flow + TZD → Oedema Dexamethasone → hyperglycemia

30. Anaesthetic Considerations: GA  risk of nerve injury  proper positioning of the extremities Cardiac autonomic neuropathy  Episodes of bradycardia and hypotension unresponsive to atropine and ephedrine  Prompt ECM & IV epinephrine may be the only effective therapy

31. Anaesthetic Considerations: RA Consent from the patient Chart any pre-existing nerve damage before block Avoid adrenaline containing local anaesthetics - harmful for the nerves that are already damaged.  requirement of local anaesthetics

32. Anaesthetic Considerations: RA Avoid hypotension by adequate hydration Intervene early with ephedrine Safe guard the pressure points Use peripheral nerve blocks whenever applicable to avoid central neuraxial blocks May be on aspirin / antiplatelet  implication Associated PVD should be in mind

33. Drugs

34. Sulfonylureas Closure of KATP channels KATP channel + in cell membranes of cardiomyocytes and vascular myocytes Different selectivity Glibenclamide being one of the least selective Asglimepiride - greater selectivity to the pancreatic KATP channels

35. Biguanides To stop or not to stop R etrospective investigation N = 1284 diabetic patients Recent metformin ingestion was not associated with  risk of adverse outcome in cardiac surgical patients In fact it gave beneficial effects Duncan et al. Recent Metformin Ingestion Does Not Increase In-Hospital Morbidity or Mortality After Cardiac Surgery. Anesth Analg 2007;104:42–50

36. GLP- 1

37. Withholding GLP-1 analogs, DPP-IV inhibitors, and pramlintide on the day of surgery is suggested. Potentially enhanced risks of Nausea Aspiration of gastric contents Hypoglycemia Pharmacologic Agents Acting via the Incretin and Amylin Pathways

38. Insulin Preparations Preparation Onset, h Peak, h Effective Duration, h Rapid-acting, subcutaneous    Lispro <0.25 0.5–1.5 3–4    Aspart <0.25 0.5–1.5 3–4   Glulisine <0.25 0.5–1.5 3–4 Short-acting, subcutaneous         Regular 0.5–1.0 2–3 4–6

39. Insulin Preparations Preparation Onset, h Peak, h Effective Duration, h Intermediate-acting         NPH 1–4 6–10 10–16 Long-acting          Detemir 1–4 — a   12–20    Glargine 1–4 — a 24 a Glargine has minimal peak activity; detemir has some peak activity at 6–14 h.

40. Insulin Preparations Preparation Onset, h Peak, h Effective Duration, h Insulin Combinations         75/25–75% protamine lispro, 25% lispro <0.25 1.5 h b   Up to 10–16   70/30–70% protamine aspart, 30% aspart <0.25 1.5 h b   Up to 10–16   50/50–50% protamine lispro, 50% lispro <0.25 1.5 h b   Up to 10–16   70/30–70% NPH, 30% regular insulin 0.5–1 Dual 10–16   50/50–50% NPH, 50% regular insulin 0.5–1 Dual 10–16 b Dual : 2 peaks; one at 2–3 h; the 2 nd several hours later.

41. Perioperative Concerns

42. Periop Hypoglycemia Long starvation Impaired nutrition Residual effects of OHA & Insulin Periop GI complications Sedation

43. Patients at risk for hypoglycaemia before operation Those with very strict glycaemic control T hose with significant daily GV T hose with complicated insulin regimens Those who are taking insulin in combination with oral antidiabetic agents

44. Periop Hyperglycemia Insulin Deficiency Insulin Resistance Counter regulatory hormones

45. ‘SIH’ Elevated BG that reverts to normal after illness subsides and counter-regulatory hormone and inflammatory mediator surge abates. Independently ↑ the risk of perioperative and critical illness morbidity & mortality. Marker for severity of illness and degree of counterregulatory hormone surge.

46. Glucose variability Degree of glucose level excursion over time It is increasingly linked to poor ICU and perioperative outcomes

47. Harmful effects of perioperative hyperglycemia Dehydration Poor wound healing Infection Inability to wean from CPB Vascular thrombosis

48. Is very tight sugar control recommended?

49. Normoglycemia in Intensive Care Evaluation – Survival Using Glucose Algorithm Regulation (NICE-SUGAR) International multicentre study N=6104 critically ill adults IIT Conventional GC Target glucose 81-108 ≤180 Mortality rates 27.5% 24.9% OR1.14, 95% CI 1.02-1.28, p=0.02 Sever hypoglycemia (BG≤40 mg/ dL ) 6.8% 0.5% ICU & hospital LOS, duration of MV, & need for RRT Same

50. CMAJ 2009;180:821-7 Meta-analysis 13,567 critically ill patients, including those enrolled in NICE-SUGAR IIT : No overall mortality benefit among critically ill patients + significantly increased the risk of hypoglycemia A potential benefit in surgical ICU patients, however could not be excluded

51. Hypoglycemia CNS Seizure, Coma, Death CVS Sympatho -adrenal activation  HR  P eripheral systoic blood BP  Myocardial contractility with  EF  Peripheral resistance Diseased CVS Myocardial ischaemia Arrhythmia

52. Recommendations for glycemic control in the periopperiod I C U Intraoperative Perioperative Between 140 and 180 mg/ dL ; generally < 180 mg/ dL < 150 mg/ dL < 140 mg/ dL premeal or < 180 mg/ dL (random) American Association of Clinical Endocrinologists and American Diabetes Association Consensus Statement on Inpatient glyemic Control. Endocr Pract 2009; 15:353-69 & Diabetes Care 2009; 32:1119-31.

53. WHO surgical safety checklist bundle Target blood glucose (BG) of 6–10 mM (108–180 mg %) (acceptable range 4–12 mM , (72–216 mg %) World Health Organization. World Health Organization Guidelines for Safe Surgery. Geneva: World Health Organization, 2009.

54. Will you be using all these for sugar measurement?

55. Blood Glucose testing Central Lab Haemodynamically & metabolically unstable patient More accurate POC Metabolically stable patient Less accurate More frequent testing Intermittent confirmation with lab Set relatively high hypoglycaemia alert value (70 mg% )

56. Surgery with short starvation (1 missed meal) Surgery with long starvation (>1 missed meal) Well controlled ( HbA < 8.5%) Yes No Short Starvation Sx Day Care guidelines Variable Rate IV Insulin Infusion (VRIII) Perioperative Glycemic Rx Sx can be deferred? No

57. Well controlled patients ( HbA <69 mmol /mol or 8.5%) undergoing surgery with a short starvation period. Can they be done on day care basis? Control Sx suitable for day case Fulfill all other Day care criteria Timing of surgery Allow Diet Yes Yes Any Yes Oral Yes Yes Early in morning or afternoon Yes Injections Yes

58. Guideline for peri -operative adjustment of non-insulin medication (short starvation period – no more than ONE missed meal) Tablets Day of surgery AM surgery PM surgery Acarbose Omit morning dose if NBM Give morning dose if eating Pioglitazone Take as normal Take as normal

59. Guideline for peri -operative adjustment of non-insulin medication (short starvation period – no more than ONE missed meal) Tablets Day of surgery AM surgery PM surgery Metformin (procedure not requiring use of contrast media*) Take as normal Take as normal * If contrast medium is to be used and eGFR < 50 mls /min/1.73m 2 , omit metformin on day of the procedure & for the following 48 hrs.

60. Guideline for peri -operative adjustment of non-insulin medication (short starvation period – no more than ONE missed meal) Tablets Day of surgery AM Surgery PM surgery Sulphonylurea ( Glibenclamide , Gliclazide , Glipizide , etc.) Once daily AM omit Twice daily omit AM Once daily AM omit Twice daily omit AM & PM Meglitinide ( repaglinide or Nateglinide ) Omit morning dose if NBM Give morning dose if eating

61. Guideline for peri -operative adjustment of non-insulin medication (short starvation period – no more than ONE missed meal) Medication Day of surgery AM surgery PM surgery DPP IV inhibitor ( Sitagliptin , Vildagliptin , Saxagliptin ) Omit on day of surgery GLP-1 analogue ( Exenatide , Liraglutide ) Omit on day of surgery

62. Guideline for peri -operative adjustment of insulin (short starvation period – no more than ONE missed meal) Insulins Day of surgery AM surgery PM surgery Once daily (evening) ( Lantus ® Levemir ®. Insulatard ®, Humulin I®, Insuman ®) Check blood glucose on admission

63. Guideline for peri -operative adjustment of insulin (short starvation period – no more than ONE missed meal) Insulins Day of surgery AM surgery PM surgery Once daily (morning) ( Lantus ® Levemir ®. Insulatard ®, Humulin I®, Insuman ®) No dose change* Check blood glucose on admission

64. Guideline for peri -operative adjustment of insulin (short starvation period – no more than ONE missed meal) Insulins Day of surgery AM surgery PM surgery Twice daily ( Novomix 30, Humulin M3® Humalog Mix 25®, Humalog Mix 50®, Insuman ® Comb 25, Insuman ® Comb 50, twice daily Levemir ® Or Lantus ®) ½ usual morning dose. Check blood glucose on admission. Leave the evening meal dose unchanged

65. Guideline for peri -operative adjustment of insulin (short starvation period – no more than ONE missed meal) Insulins Day of surgery AM surgery PM surgery 3, 4, or 5 injections daily Basal bolus regimens: Omit the morning and lunchtime short acting insulins . Keep the basal unchanged.* Premixed AM insulin: ½ morning dose & omit lunch time dose Check blood glucose on admission Take usual morning insulin dose(s). Omit lunchtime dose. Check blood glucose on admission

66. Guideline for peri -operative monitoring of diabetes and management of hyperglycaemia and hypoglycaemia in patients undergoing surgery with a short starvation period (one missed meal) Monitor capillary blood glucose on admission and hourly during the day of surgery. Aim for blood glucose level 6-10 mmol /L (108-180 mg%); 4-12 mmol /L (72-216 mg%) is acceptable.

67. Rx of Preop hyperglycaemia BG>216 mg% Capillary blood ketones > 3 mmol /L or urinary ketones > +++ Yes Cancel surgery Follow DKA guidelines Refer to diabetologist No Type 1 SC rapid insulin 1 unit → ↓ BG by 54mg% Recheck 1 hour later to ensure it is falling If surgery cannot be delayed → VRIII® Type 2 0.1 units/kg SC rapid acting analogue insulin

68. Rx of Postop hyperglycaemia BG>216 mg% Capillary blood ketones > 3 mmol /L or urinary ketones > +++ Yes Follow DKA guidelines Refer to diabetologist No Type 1 SC rapid insulin 1 unit → BG by 54mg% Repeat SC insulin (same or ↑) after 2 hrs if BG is >216mg%. Recheck after 1 hr. If it is not falling consider introducing VRIII Type 2 0.1 units/kg SC rapid acting analogue insulin

69. Management of hypoglycaemia and hypoglycaemia risk Consider the potential for hypoglycaemia if the admission CBG < 108 mg% Patients on diet alone are not at risk of hypoglycaemia If CBG is 72-108 mg% + symptoms of hypoglycaemia: →50-100mls of 10% D stat iv and repeat the CBG after 15 minutes If CBG < 72 mg% → 80-100 mls of 20% D and repeat CBG after 15 minutes

70. Variable Rate Intravenous Insulin Infusion (VRIII) Make up a 50 ml syringe with 49.5mls of 0.9% NaCl + 50 units regular insulin Initial crystalloid solution to be co-administered with the VRIII is 0.45% saline with 5% glucose and 0.15% KCl at daily maintenance rate. Selection based on s. Electrolytes daily

71. Rate of insulin infusion C BG ( mmol /L) C BG (mg%) Insulin (units/ h) <4.0 <72 0.5* 4.1-7.0 72- 126 1 7.1-9.0 127 - 162 2 9.1-11.0 163- 199 3 11.1-14.0 200 -252 4 14.1-17.0 253- 306 5 17.1-20 307-360 6 >20 >360 Refer (0.0 if a long acting background insulin has been continued)

72. Guideline for the use of a variable rate intravenous insulin infusion (VRIII) There is no one fit for all If the patient is already on a long acting insulin analogue (e.g. Levemir ® or Lantus ®) these should be continued Heavier patients often require more insulin per hour

73. Guideline for the use of a variable rate intravenous insulin infusion (VRIII) Hourly bedside CBG measurement initially to ensure that rate is correct If CBG > 216mg% for 3 consecutive readings & is not dropping by 54mg%/hr or more the rate of insulin infusion should be increased

74. Guideline for the use of a variable rate intravenous insulin infusion (VRIII) If CBG is < 72 mg%, Insulin infusion rate should be ↓ to 0.5 units / h & low blood glucose should be treated as per the National Guideline irrespective of symptoms +/-. However, if the patient has continued on their long acting background insulin, VRII can be switched off, But continue regular CBG measurements

75. Continue until the patient is eating and drinking and back on their usual glucose lowering medication Guideline for the use of a variable rate intravenous insulin infusion (VRIII)

76. Transferring from a VRIII to oral treatment Recommence oral hypoglycaemic agents at pre-operative doses once the patient is ready to eat and drink Be prepared to withhold or reduce sulphonylureas if the food intake is likely to be reduced Metformin should only be recommenced if the eGFR is greater than 50 mls /min/1.73m 2

77. Transferring from a VRIII to subcutaneous insulin Once patient is able to eat / drink without nausea or vomiting Restart the normal pre-surgical regimen The transition from IV to SC insulin should take place when the next meal-related SC insulin dose is due e.g. with breakfast or lunch There should be an overlap between the VRIII and the first injection of fast acting insulin

78. Fluid management for patients not requiring a VRIII NS Hyperchloremic Acidosis LR ?Hyperglycemia 1L LR → maximum 261 mg glucose Rapid infusion of 1L LR →↑ plasma glucose by no more than 18 mg% √

79. Fluid management for patients requiring a VRIII Aims Prevention of gluconeogenesis , lipolysis , ketogenesis and proteolysis Maintenance of a blood glucose level between 108-180 mg% (72-216 mg% is acceptable) Maintenance of euvolaemia Maintenance of serum electrolytes within the normal range

80. Fluid management for patients requiring a VRIII Types

81. Insulin Sliding Scale Estimate sensitivity using "rule of 1500" BG change per unit Insulin = 1500 / total daily Insulin Goal Blood Glucose is <150 Example: If TDD = 30 units/day: 1 unit drops BG by 50 mg% If BG 250: 2 unit bolus Insulin (regular or RA)

82. Alberti’s Regimen Glucose Insulin potassium (GIK) Regimen Normal renal function & normal K+ levels Dextrose 5% 1L + potassium 10-20 meq + 16 IU insulin Accidentally if infusion rate is  , extra dextrose also will go  less chances of hypoglycemia If insulin requirement changes  will have to prepare another one

83. Crisis in Diabetes Mellitus Crisis in Diabetes - Coma Hypoglycemic Hyperglycemic Ketoacidosis Hyperosmolar nonketotic Mixed

84. DKA: Clinical Picture Anorexia, nausea, and vomiting Polyuria and polydipsia Abdominal pain may be present Altered consciousness or frank coma Kussmaul respiration (gasping for breath - which also smells of acetone) Signs of dehydration Temperature is normal. Fever  infection. Leukocytosis  diabetic acidosis per se & may not indicate infection

85. DKA: Clinical Picture Metabolic acidosis and widened anion gap (mainly  acetoacetate & beta- hydroxybutyrate , although lactate, FFA, phosphates contribute) Initial potassium & phosphorus conc. – N /  , But total-body deficit + "Spurious Hyponatraemia " Pseudohyponatremia ∵ severe hypertriglyceridemia Hypertriglyceridemia Prerenal failure, reflecting volume depletion  serum amylase - frank pancreatitis

86. DKA: Principles of management Acidosis is more imp. than the hyperglycaemia , more difficult to treat & lasts longer Insulin is administered until the acidosis has been reversed and the urine ketone negative, even if glucose comes back to normal Profound volume depletion (usually 3 - 8 litres ) requires aggressive volume resuscitation Key parameters to follow are pH & the calculated anion gap. The usual picture is for the pH to rise and the anion gap to narrow even though the bicarbonate level remains low

87. DKA: Exact Plan of Management ABC Blood & urine for ketones , glucose & microbiology, CXR Actrapid 10 to 20 IU iv stat  insulin infusion IV Fluid: 1 litre NaCl 0.9% stat, then 1 L over 30 mins , 1L over 1 hour, 1L over 2 hours, 4 hours and then 8 hourly. Add 10 - 20 mmol KCL or KPO 4 to 2nd and subsequent litres of fluid. When b glucose < 270mg% replace NaCL with DNS Broad spectrum antibiotics Bicarbonate is not usually required

88. Persistent ketonuria : Should I go ahead withy emergency Sx ? Ketone bodies are acetone, acetoacetate , & beta – hydroxybutyrate After Rx with fluids & insulin, betahydroxybutyrate levels  rapidly, where as acetoacetate levels may remain stable or may even  before declining. Plasma acetone levels remain elevated for 24 to 72 hrs, long after blood glucose, beta hydroxybutyrate and acetoacetate levels have returned to normal. So, results in continuing ketonuria .

89. Hyperosmolar Coma Usually with type II DM Absence of ketoacidosis is imp. When ketoacidosis develops, nausea, vomiting, and air hunger bring the patient to the physician before extreme dehydration can occur. Such a protective mechanism is not operative in these cases

90. Hyperosmolar Coma: Presenting Features Extreme hyperglycemia (>600mg%, much higher than DKA) Hyperosmolality Severe volume depletion CNS signs - drowsiness to coma A high index of suspicion for infection Plasma viscosity is high  thrombosis Bleeding (caused by DIC) Acute pancreatitis

91. Hyperosmolar Coma: Management Most imp. measure is rapid administration of large amounts of IV fluids. Average fluid deficit is 10 to 11 L Fluid resuscitation with 0.45% saline ABC IV access and blood sampling IV insulin 10 IU actrapid stat. Insulin infusion according to sliding scale Broad spectrum antibiotics

92. DKA   Hyperosmolar coma Diabetic symptoms (polyuria, polydipsia, Weakness, blurred vision) ++  +++ Dehydration  +/++  +++ Acidosis  ++  +/- Nausea, vomiting, abdominal pain ++  +/- Neurologic impairment  +/- ++ Fever     +/- +/- Hypothermia   +/- - Renal insufficiency - +/++ Cardiac symptoms  - +/++ Neurological deficit - +/++

93. DKA Hyperosmolar Mixed GLUCOSE (MG/DL)  >250 >600 >600 PH < 7.3 ≥ 7.3 ≤ 7.3 BICARBONATE (MEQ/L) < 15 > 15 < 15 OSMOLALITY (MOSM/KG) < 320 >320 > 320 SERUM/URINE KETONES ++ -/+ ++ DEHYDRATION ↑↑ ↑↑↑ ↑↑

94. Hypoglycemic crisis under anaesthesia Usual symptoms of diaphoresis, hunger tremors, palpitation are hidden by GA High index of suspicion is must Hypertension, tachycardia, sweating, cold skin Frequent monitoring of blood glucose Rx - provide supplemental glucose

95. Key Points Diabetes is a multisystem disorder Thorough preop evaluation is needed to rule out diabetes induced complications Extra care is needed in patients with autonomic neuropathy, cardiomyopathy , and diabetic related kidney disease Patients undergoing long / complex surgeries who are going to miss > 1 meal require VRII

96. Key Points Maintain Target blood glucose (BG) of 6–10 mM (108–180 mg %) A cceptable range 4–12 mM , (72–216 mg %)

97. Key Points: DKA Preop - resuscitate the patient yourself in a HDU Delay surgery for as long as possible to allow adequate resuscitation. At the very least, achieve volume resuscitation & correction of the acidosis Continue IV insulin throughout peri -op period

98. Key Points: Hypoglycemia Be paranoid of hypoglycaemia in patients on OHAs Blood sugar levels that constitute euglycaemia for non diabetics will cause symptoms of hypoglycaemia in diabetic patients

99. Monitor & Control sugar Have a Nice Day ! Thank You