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1. ANESTHESIA AND ENDOCRINE DISEASE FOR 4TH YEAR ANESTHESIA STUDENTS Anesthesia M anagement F or P atients with Diabetes M ellitus By: Abdurahman Tune(BSc, MSc in clinical anesthesia) 12/23/2019 1

2. Contents Introduction Types of DM Complication of DM Anesthesia concerns about DM 12/23/2019 2

3. Objective At the end of this cession students will be able to :- Define what is DM Lists down types of DM Manage patients with DM who came for surgery 12/23/2019 3

4. Introduction to DM Diabetes mellitus (DM) refers to a group of common metabolic disorders that share the phenotype of hyperglycemia. Several distinct types of DM exist and are caused by a complex interaction of genetics and environmental factors. Depending on the etiology of the DM, factors contributing to hyperglycemia include:- Reduced insulin secretion Decreased glucose utilization and Increased glucose production 12/23/2019 4

5. Introduction to DM cont’d…. In the United States, DM is the leading cause of different health problem of :- End-stage renal disease (ESRD) Non-traumatic lower extremity amputations Adult blindness It also predisposes to cardiovascular diseases. With an increasing incidence worldwide, DM will be a leading cause of morbidity and mortality for the future. 12/23/2019 5

6. Introduction to DM cont’d…. Physiology of Insulin:- The most fundamental action of insulin is to stimulate cellular uptake of glucose in skeletal muscle cells& adipose tissue A patient with diabetes has hyperglycemia because of inadequate cellular uptake of glucose in muscle, adipose tissue and cardiac cells Other important metabolic functions of insulin include:- The stimulation of glycogen formation and The suppression of gluconeogenesis and lipolysis 12/23/2019 6

7. Introduction to DM cont’d…. A fasting glucose level below 100 mg/dl is considered normal. Those with levels between 100 and 125 mg/dl (hba1c 5.7 to 6.4) are considered pre-diabetics Individuals with documented fasting glucose levels above 126 mg/dl (hba1c ≥6.5%) are considered diabetics DM is the most commonly occurring endocrine disease found in surgical patients, and 25% to 50% of diabetics will require surgery at some point in their lives. 12/23/2019 7

8. Classification of DM DM is classified on the basis of the pathogenic process that leads to hyperglycemia. DM is classified into four broad types: Type 1 diabetes ( IDDM) Type 2 diabetes( insulin resistance) Gestational DM and Diabetes due to other causes. 12/23/2019 8

9. Classification of DM cont’d…. Type 1 (juvenile-onset Diabetes) is due to pancreatic β-cell destruction, usually leading to absolute insulin deficiency. It accounts for 5% to 10% of all DM cases Type 2 DM (adult-onset) is a heterogeneous group of disorders characterized by:- Variable degrees of insulin resistance Impaired insulin secretion and Increased glucose production. Type 2 DM is preceded by a period of abnormal glucose homeostasis classified as impaired fasting glucose (IFG) or impaired glucose tolerance (IGT). The diagnosis is based on an elevated fasting plasma glucose greater than 126 mg/dL or glycated hemoglobin (HbA 1c ) of 6.5% or greater. 12/23/2019 9

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12. Classification of DM cont’d…. Other types of DM can be a result of a disease that damages the pancreas and thus impairs insulin secretion. Pancreatic surgery chronic pancreatitis cystic fibrosis and hemochromatosis can damage the pancreas and impair insulin secretion sufficiently to produce clinical DM Treatment of human immunodeficiency virus/acquired immunodeficiency syndrome Genetic defects in β-cell function and Genetic defects in insulin action can also induce diabetes (monogenic diabetes). 12/23/2019 12

13. Classification of DM cont’d…. Gestational diabetes is typically diagnosed in the second or third trimester of pregnancy and may presage future type 2 DM. Different diagnostic criteria are used to diagnose gestational diabetes . Gestational diabetes develops in more than 3% of all pregnancies and increases the risk of type 2 diabetes by 17% to 63% within 15 years. 12/23/2019 13

14. Diagnosis of DM 12/23/2019 14

15. Type 1 Diabetes Mellitus 5% to 10% of all cases of diabetes are type 1. Currently, incidence is increasing by 3% to 5% per year. It is usually diagnosed before the age of 40 years and is one of the most common chronic childhood illnesses In type 1 diabetes, the patient is insulin deficient and susceptible to ketoacidosis if insulin is withheld 12/23/2019 15

16. Type 1 Diabetes Mellitus cont’d… Type 1 diabetes is caused by a T cell–mediated autoimmune destruction of beta cells of the pancreas At least 80% to 90% of beta-cell function must be lost before hyperglycemia occurs Patients demonstrate hyperglycemia over several days to weeks associated with:- Fatigue Weight loss Polyuria Polydipsia Blurring of vision, and Signs of intravascular volume depletion 12/23/2019 16

17. Type 1 Diabetes Mellitus cont’d… Type 1 diabetes is associated with a 15% prevalence of other autoimmune diseases including:- Graves disease Hashimoto thyroiditis Addison disease and Myasthenia gravis 12/23/2019 17

18. Type 1 Diabetes Mellitus cont’d… The diagnosis is based on the following symptoms: A random blood glucose greater than 200 mg/dl and A hemoglobin (Hb) a 1c level greater than 6.5 %. The presence of ketoacidosis indicates severe insulin deficiency and unrestrained lipolysis. Beta-cell destruction is complete within 3 years of diagnosis in most young children, with the process being slower in adults. 12/23/2019 18

19. Type 2 Diabetes Type 2 diabetes is responsible for 90% to 95% of all cases of diabetes mellitus in the world Type 2 diabetics are typically in the middle to older age group and overweight has been a significant increase in younger patients and even children over the past decade. Type 2 diabetes continues to be under recognized and under diagnosed because of its subtle presentation. It is estimated that most type 2 diabetics have had the disease for approximately 4 to 7 years before it is diagnosed 12/23/2019 19

20. Type 2 Diabetes cont’d… Type 2 diabetes is characterized by :- Relative beta-cell insufficiency and Insulin resistance There are three important defects in type 2 diabetes: An increased rate of hepatic glucose release Impaired basal and stimulated insulin secretion and Inefficient use of glucose by peripheral tissues (i.e., Insulin resistance) 12/23/2019 20

21. Treatment of type 2 DM The cornerstones of therapy for type 2 diabetes are:- Diet with weight loss Exercise therapy, and The oral anti-diabetic agents . Reduction of body weight through diet and exercise is the first therapeutic measure to control type 2 diabetes 12/23/2019 21

22. Treatment of type 2 DM Oral Anti-diabetic Agents The four major classes of oral agents are :- 1. secretagogues (sulfonylureas, meglitinides) which increase insulin availability 2. Biguanides (metformin), which suppress excessive hepatic glucose release 3. Thiazolidinediones or glitazones (rosiglitazone, pioglitazone), which improve insulin sensitivity and 4. α- glucosidase inhibitors ( acarbose , miglitol ) which delay gastrointestinal glucose absorption 12/23/2019 22

23. Treatment of type 2 DM cont’d… These agents, either as mono-therapy or in various combinations, are used to maintain glucose control Fasting glucose, 90–130 mg/dl Peak postprandial glucose <180 mg/dl Hb a 1c <7%) in the initial stages of the disease 12/23/2019 23

24. Treatment of Type 1 DM Insulin Insulin is necessary to manage all type 1 diabetics and many type 2 diabetics Conventional insulin therapy uses twice-daily injections. Intensive insulin therapy uses three or more daily injections or a continuous infusion. 12/23/2019 24

25. Insulin treatment Insulin is a small protein produced by the β cells of the islets of Langerhans in the pancreas. The basal rate of insulin secretion is about 1 unit/ hr , which can increase by 5- to 10-fold after ingestion of food. Normal production in the adult human is approximately 40 to 50 units/day. Insulin acts through its specific receptor on cells. The half-life of insulin in the circulation is 5 minutes. 12/23/2019 25

26. Insulin treatment cont’d… However, it may clinically appear to have a longer duration of action, due to delays in binding and release from the cellular receptors. Insulin is metabolized in the liver and kidneys. P atients with renal and hepatic disease the action of insulin is prolonged. They are more prone to hypoglycemia, and exogenous insulin should be administered judiciously in diabetic patients with renal disease. 12/23/2019 26

27. Insulin treatment cont’d… The most fundamental action of insulin is to stimulate cellular uptake of glucose in skeletal muscle cells, adipose tissue, and cardiac cells. This is particularly important in skeletal muscle cells, where muscle activity also increases glucose uptake and is an important variable in the management of the physically active diabetic patient. The brain, liver, and immune cells are exceptions , where insulin does not affect glucose transport. 12/23/2019 27

28. Insulin treatment cont’d… Along with glucose, potassium enters the cells under the influence of insulin, so the diabetic patient is also likely to have an imbalance of potassium concentrations across cell membranes . Plasma potassium- (K+) levels can be elevated because metabolic acidosis drives K+ from the intracellular space to extracellular fluids. Insulin concentrations are insufficient to maintain intracellular K+ levels, so total body K+ actually is depressed (reduced by 3-10 mEq per kilogram body weight ). 12/23/2019 28

29. Insulin treatment cont’d… Rapid potassium administration can precipitate dysrhythmias. Potassium can be replaced with an equal mixture of potassium chloride and potassium phosphate. Serum K+ <3 mEq/L, give K+, 40 mEq/h Serum K+ <4 mEq/L, give K+, 30 mEq/h Serum K+ <5 mEq/L, give K+, 20 mEq/h Serum K+ ≥5 mEq /L, no replacement 12/23/2019 29

30. Insulin treatment cont’d… During stress, elevations in the circulating levels of cortisol, glucagon, catecholamine's, and growth hormone all act to stimulate gluconeogenesis and glycogenolysis and cause hyperglycemia . In addition , glucagon and adrenergic stimulation exert a suppressive effect on insulin release . Inflammatory mediators released during stress enhance the release of the counter-regulatory hormones and directly affect the intracellular signaling pathways of insulin, culminating in significant insulin resistance 12/23/2019 30

31. Insulin treatment cont’d… Hence, mild hyperglycemia may occur in the stressed patient who does not have DM. In a patient with minimal or subclinical DM before the stressful episode, the hyperglycemia may become difficult to manage during the stress-related event and many patients require additional insulin to manage hyperglycemia Hyperglycemia in a hospital setting is defined as any blood glucose higher than 140 mg/ dL . 12/23/2019 31

32. Insulin treatment cont’d… The various forms of insulin include:- Basal insulin's, which are intermediate acting (NPH, lente, lispro protamine, aspart protamine) and administered twice daily or Long acting (ultralente and glargine) and administered once daily, and Insulins that are short acting (regular) or rapid acting (lispro, aspart), which provide glycemic control at mealtimes (prandial insulin). 12/23/2019 32

33. Properties of Common Insulin Preparations 12/23/2019 33

34. Complication of DM Long-term complications of diabetes include:- 1 . Micro vascular    Eye disease      Retinopathy (non-proliferative/proliferative)      Macular edema    Neuropathy      Sensory and motor (mono- and poly-neuropathy)      Autonomic    Nephropathy 12/23/2019 34

35. Complication of DM cont’d… 2. Macro vascular    Coronary artery disease    Peripheral arterial disease    Cerebrovascular disease 12/23/2019 35

36. Complication of DM cont’d… 3. Other    Gastrointestinal (gastroparesis, diarrhea)    Genitourinary (uropathy/sexual dysfunction)    Dermatologic    Infectious    Cataracts    Glaucoma    Periodontal disease 12/23/2019 36

37. Acute complication of DM There are three life-threatening acute complications of diabetes DKA Hyperosmolar non- ketotic coma and Hypoglycemia 12/23/2019 37

38. Acute complication of DM 1. DKA Decreased insulin activity allows the catabolism of free fatty acids into ketone bodies (acetoacetate and β- hydroxybutyrate) Accumulation of these organic acids results in DK, an anion-gap metabolic acidosis. DKA can easily be distinguished from lactic acidosis, with which it can coexist; lactic acidosis is identified by elevated plasma lactate (>6 mmol/L ) and the absence of urine and plasma ketones (although they can occur concurrently and starvation ketosis may occur with lactic acidosis) 12/23/2019 38

39. DKA cont’d.. Infection is a common precipitating cause of DKA in a known diabetic patient Clinical manifestations of DKA include:- Tachypnea (respiratory compensation for the metabolic acidosis) Abdominal pain Nausea and vomiting and Changes in sensorium. 12/23/2019 39

40. Treatment of DKA cont’d.. The treatment of DKA should include:- Correcting Hypovolemia Correcting the hyperglycemia and Correcting the total body potassium deficit. This is typically accomplished with a continuous infusion of isotonic fluids and potassium and an insulin infusion. 12/23/2019 40

41. Treatment of DKA cont’d.. The maximum rate of decline in glucose is fairly constant and averages 75 to 100 mg/dL/hour, regardless of the dose of insulin. Insulin therapy is initiated with a 10-unit intravenous bolus of regular insulin, followed by continuous insulin infusion. Therapy generally begins with an intravenous insulin infusion at 0.1 units/kg/h. DKA patients may be resistant to insulin The insulin infusion rate may need to be increased if glucose concentrations do not decrease. 12/23/2019 41

42. Treatment of DKA cont’d.. As glucose moves intracellular, so does potassium. This can quickly lead to a critical level of hypokalemia if not corrected Overaggressive potassium replacement can lead to an equally life-threatening hyperkalemia. Potassium and blood glucose should be monitored frequently during treatment of DKA. 12/23/2019 42

43. Treatment of DKA cont’d.. The most important electrolyte disturbance in diabetic ketoacidosis is depletion of total-body potassium. Deficits range from 3 to 10 mEq/kg body weight. Serum potassium levels decline rapidly within 2 to 4 hours after the start of intravenous insulin administration. 12/23/2019 43

44. Treatment of DKA cont’d.. Aggressive replacement therapy is required. The potassium administered moves into the intracellular space with insulin as the acidosis is corrected. Several liters of 0.9% saline may be required to correct dehydration in adult patients. 12/23/2019 44

45. Treatment of DKA cont’d.. When plasma glucose decreases to 250 mg/dL, an infusion of D 5 W should be added to the insulin infusion to decrease the possibility of hypoglycemia. Patients may benefit from precise monitoring of urinary output during initial treatment of DKA. Bicarbonate is rarely needed to correct severe acidosis (pH < 7.1) 12/23/2019 45

46. 2 . Hyperosmolar non- ketotic coma Ketoacidosis is not a feature of Hyperosmolar non- ketotic coma possibly because enough insulin is available to prevent ketone body formation. Instead, a hyperglycemia-induced diuresis leads to dehydration and hyperosmolality . 12/23/2019 46

47. Hyperosmolar non- ketotic coma cont’d…. Severe dehydration may eventually lead to:- Kidney failure Lactic acidosis and A predisposition to form intravascular thrombosis Hyperosmolality (frequently exceeding 360 mOsm /L) induces dehydration of neurons This causing changes in mental status and seizures. Severe hyperglycemia causes hyponatremia 12/23/2019 47

48. Hyperosmolar non- ketotic coma cont’d…. Treatment includes :- Fluid resuscitation with normal saline Relatively small doses of insulin and Potassium supplementation . 12/23/2019 48

49. 3 . Hypoglycemia Hypoglycemia in the diabetic patient is the result of an absolute or relative excess of insulin relative to carbohydrate intake and exercise. Diabetic patients are incompletely able to counter hypoglycemia despite secreting glucagon or epinephrine (counter regulatory failure). 12/23/2019 49

50. Hypoglycemia cont’d…. The dependence of the brain on glucose as an energy source makes it the organ most susceptible to episodes of hypoglycemia. If hypoglycemia is not treated, mental status changes can progress from anxiety, lightheadedness, or confusion to convulsions and coma. 12/23/2019 50

51. Hypoglycemia cont’d…. Systemic manifestations of hypoglycemia result from catecholamine discharge and include:- Diaphoresis Tachycardia and Nervousness Most of the signs and symptoms of hypoglycemia will be masked by general anesthesia. Medically important hypoglycemia is present when plasma glucose is less than 50 mg/dL. 12/23/2019 51

52. Hypoglycemia cont’d…. The treatment of hypoglycemia in anesthetized or critically ill patients consists of intravenous administration of 50% glucose Awake patients can be treated orally with fluids containing glucose or sucrose. 12/23/2019 52

53. Management of Anesthesia The goals of anesthetic management of the diabetic patient include:- A thorough preoperative evaluation An in depth understanding of the pathophysiology of diabetes and the metabolic stress response A significant knowledge and understanding of insulin and Possibly collaboration with the patient’s internist/endocrinologist. 12/23/2019 53

54. Management of Anesthesia cont’d… The stress response of surgery creates the classic hyperglycemic challenge. Activation of the sympathetic nervous system and release of catecholamine may convert a well-controlled diabetic to one with significant hyperglycemia and even ketoacidosis 12/23/2019 54

55. Management of Anesthesia cont’d… The effects of chronic hyperglycemia like :- coronary artery disease myocardial infarction congestive heart failure peripheral vascular disease should be medically optimized pre op. hypertension cerebrovascular accident chronic renal failure infection neuropathy The effects of acute hyperglycemia are also dangerous and must be managed 12/23/2019 55

56. Management of Anesthesia cont’d… Acute hyperglycemia causes:- dehydration impaired wound healing an increased rate of infection worsening central nervous system/spinal cord injury with ischemia, and hyper viscosity with thrombogenesis Tight control of serum glucose in the perioperative period is important in managing the consequences of acute and chronic hyperglycemia. 12/23/2019 56

57. Management of Anesthesia cont’d… Preoperative Preoperative evaluation and management has three important goals: One is determining end-organ complications of DM. This requires a thorough history and physical, a recent ECG, blood urea nitrogen, potassium, creatinine, glucose , and urinalysis . Second is determining the patient’s glucose-lowering regimen . Patients may be on different types of insulin regimens and oral hypoglycemic agents . Preoperative counseling has to be specific to the patient’s glucose-lowering regimen . The third goal is to determine patient glycemic control and the need for preoperative intervention to control glucose levels. 12/23/2019 57

58. Management of Anesthesia cont’d… The preoperative evaluation should emphasize the cardiovascular renal neurologic and musculoskeletal systems . A high index of suspicion should exist for myocardial ischemia and infarction. Silent ischemia is possible if an autonomic neuropathy is present. 12/23/2019 58

59. Management of Anesthesia cont’d… Atherosclerosis develops earlier and is more widespread in diabetic patients compared with non-diabetics . Manifestations include coronary artery disease, peripheral vascular disease, cerebrovascular disease, and reno -vascular disease. The incidence of postoperative myocardial infarction is increased in diabetic patients, and the complication rate is higher. 12/23/2019 59

60. Management of Anesthesia cont’d… Diabetic nephropathy occurs in 20% to 40% of patients with diabetes and is the leading cause of end-stage renal disease (ESRD ). Diabetic patients may also have GI neuropathies (e.g., esophageal enteropathy , gastroparesis, constipation, diarrhea, fecal incontinence). They may have delayed gastric emptying, and therefore they may be at increased risk of pulmonary aspiration of gastric contents . D iabetic stiff joint syndrome, a frequent complication of type 1 DM, leading to decreased mobility of the atlanto -occipital joint which leads to difficulty intubation 12/23/2019 60

61. Management of Anesthesia cont’d… Abnormally elevated hemoglobin A 1c concentrations identify patients who have maintained poor control of blood glucose over time. These patients may be at greater risk for:- perioperative hyperglycemia perioperative complications and adverse outcomes. 12/23/2019 61

62. Management of Anesthesia cont’d… The perioperative morbidity of diabetic patients is related to their preexisting end-organ damage. One third to one half of patients with type 2 diabetes mellitus may be unaware of their condition. 12/23/2019 62

63. Management of Anesthesia cont’d… Management of insulin in the preoperative period depends on the type of insulin that the patient takes and the timing of dosing If a patient takes subcutaneous insulin each night at bedtime:- Two thirds of this dose (NPH - neutral protamine hagedorn ; intermediate-acting and regular) should be administered the night before surgery and One half of the usual morning NPH dose should be given on the day of surgery. The daily morning dose of regular insulin should be held 12/23/2019 63

64. Management of Anesthesia cont’d… A 5% dextrose with 0.45% normal saline (D 5 ½ NS) intravenous infusion at 100 mL/hr should be initiated preoperatively. Oral hypoglycemic should be discontinued 24 to 48 hours preoperatively. The sulfonylureas should also be avoided during the entire perioperative period since they block myocardial potassium adenosine triphosphate channels, which are responsible for ischemia- and anesthetic-induced preconditioning. 12/23/2019 64

65. Management of Anesthesia cont’d… Well-controlled type 2 diabetics do not require insulin for minor surgery. Poorly controlled type 2 diabetics and all type 1 diabetics having minor surgery and all diabetics having major surgery need insulin. For major surgery, if the serum glucose is greater than 270 mg/dL preoperatively, the surgery should be delayed while rapid control is achieved with intravenous insulin. If the serum glucose is greater than 400 mg/dL, the surgery should be postponed and the metabolic state restabilized . Some institutions have used a cutoff value of 300 mg/dl as a trigger in the preoperative area for evaluation for ketoacidosis via either urine ketone dipstick or whole blood chemistry 12/23/2019 65

66. Intraoperative Management Aggressive glycemic control is important intraoperatively. Two major goals are To minimize hyperglycemia and Avoid hypoglycemia. Ideally, a continuous infusion of insulin should be initiated at least 2 hours before surgery. A sliding scale with short-acting, subcutaneous insulin for glucose greater than 200 to 250 mg/dL is ineffective and should not be used. 12/23/2019 66

67. Management of Anesthesia cont’d… Intraoperative serum glucose levels should be maintained between 120 and 180 mg/dL. Levels above 200 mg/dL are likely to be detrimental in the perioperative period causing Glycosuria Dehydration Inhibiting phagocyte function and wound healing. 12/23/2019 67

68. Management of Anesthesia cont’d… Typically, one unit of insulin lowers glucose approximately 25 to 30 mg/dL. The initial hourly rate for a continuous insulin infusion is determined by dividing the total daily insulin requirement by 24. A typical rate is 0.02 U/kg per hour or 1.4 U/hr in a 70-kg patient 12/23/2019 68

69. Management of Anesthesia cont’d… An insulin infusion can be prepared by mixing 100 units of regular insulin in 100 mL NS (1 U/mL). Insulin infusion requirements are higher for:- Coronary artery bypass graft surgery (0.06 U/kg per hour) Patients receiving steroids (0.04 U/kg per hour) Patients with severe infection (0.04 U/kg per hour) and Patients receiving hyperalimentation or vasopressor infusions 12/23/2019 69

70. Management of Anesthesia cont’d… Insulin infusions should be accompanied by an infusion of D 5 ½ NS with 20 mEq KCl to inhibit hepatic glucose production and protein catabolism. Serum glucose should be monitored every hour and every 30 minutes 12/23/2019 70

71. Management of Anesthesia cont’d… For serum glucose values less than 100 mg/dl, the D5 1/2 NS infusion rate should be 150 ml/ hr For 100 to 150 mg/dl, it should be 75 ml/ hr For 151 to 200 mg/dl, it should be 50 ml/ hr 12/23/2019 71

72. Management of Anesthesia cont’d… Avoidance of hypoglycemia intraoperatively and postoperatively is especially critical since its recognition may be delayed by anesthetics sedatives analgesics β-blockers sympatholytics, and an autonomic neuropathy. Hypoglycemia is defined as a serum glucose less than 50 mg/dL in adults and 40 mg/dL in children. Treatment consists of 50 mL of 50% dextrose (i.e., D50), which increases the glucose 100 mg/dL or 2 mg/dL/ mL. 12/23/2019 72

73. Management of Anesthesia cont’d… Emergency Surgery Emergency surgery places diabetics at risk of developing DKA or HHS. Surgery should be delayed for 4 to 6 hours to optimize the patient’s metabolic status. DKA is more likely to develop in type 1 diabetics and is usually precipitated by:- infection gastrointestinal obstruction or trauma in the surgical patient 12/23/2019 73

74. Management of Anesthesia cont’d… Emergency patients may present with:- hyperglycemia hyperosmolality significant dehydration ketosis, and acidosis Total body deficits of sodium and potassium are present, and frequently phosphate and magnesium deficits exist 12/23/2019 74

75. Management of Anesthesia cont’d… Treatment includes large volumes of normal saline and insulin. An insulin bolus of 0.1 U/kg followed by an infusion of 0.1 U/kg per hour is the initial prescription. Serum glucose is monitored hourly, and electrolytes are monitored every 2 hours. Potassium, magnesium, and phosphate deficits are replaced when urine production is documented. 12/23/2019 75

76. Management of Anesthesia cont’d… When serum glucose decreases to less than 250 mg/dL, intravenous fluids should include dextrose. Insulin is continued until acidosis resolves. Sodium bicarbonate is not routinely given and is reserved for cases where the pH is less than 7.10. 12/23/2019 76

77. Postoperative Care Aggressive insulin therapy in the intensive care unit (ICU) has demonstrated significant benefit in morbidity and mortality The postoperative management of diabetics requires meticulous monitoring of insulin requirements. The predischarge 24-hour inpatient insulin requirement should be compared to the preoperative outpatient insulin dose 12/23/2019 77

78. Summary Types of DM Acute & Chronic complication of DM Anesthesia concerns about patients with DM Intraoperative serum glucose levels should be maintained between 120 and 180 mg/ dL . 12/23/2019 78

79. Reference Harrison 18 th edition Miller anesthesia 8 th edition Morgan & Michel 5 th edition Stolening Anaesthesia & coexistind 5 th edition Barash clinical anesthesia 8 th edition 12/23/2019 79