Diabetic Stiff Joint Syndrome

1. Stiff Joint Syndrome in Diabetes: a Potential for Difficult A irway Keara L affey, SRNA Case Western Reserve University/Cleveland Clinic OSANA Fall Meeting September 13, 2015

2. Objectives State the incidence and pathology of Stiff Joint Syndrome Discuss the incidence of difficult laryngoscopy in patients with long standing DM as it relates to Stiff Joint Syndrome Describe two screening tools to assess for difficult laryngoscopy in the diabetic patient and understand how to interpret the results

3. Diabetes Statistics International Diabetes Federation Worldwide 387 million living with diabetes worldwide, 8.3% 1/12 people with diabetes worldwide American Diabetes Association 29.1 million Americans, 9.3% of population 86 million Americans have pre-diabetes By 2050 1 in 3 Americans will have diabetes if the current trend continues

4. Diabetes in Surgery 25%-50% require surgery Most common endocrine abnormality in surgical population Higher morbidity and mortality Often undiagnosed

5. Complications of Diabetes Atherosclerosis Nephropathy Neuropathy Stiff Joint Syndrome

6. Stiff Joint S yndrome First described by Dr. Arlan Rosenbloom in 1974 Also referred to as Diabetic Cheiroarthropathy or Limited Joint Mobility Most common, earliest occurring complication of Type 1 DM, also frequent occurrence in Type 2 DM Linked to duration and control of diabetes

7. Stiff Joint Syndrome Patient Characteristics Joint contractures Begins in fifth finger and progresses radially Thick, tight, waxy skin S hort stature Microvascular complications Symmetrical Painless, non- disabling

8. Stiff Joint Syndrome Prevalence Up to 50% of Type 1 DM As high as 75% of Type II DM Causes Chronic hyperglycemia  glycosylation  increased protein-protein cross-linkage  clinical stiffness Microvascular disease  hypoxia  cellular hyperplasia

9. Stiff Joint Syndrome Diagnosis Goniometry Prayer Sign Palm Print Test

10. Grade 0 Grade 1 Grade 2 Grade 3

11. Research Diabetes and difficult laryngoscopy Hogan et al., 1988; Reisssel et al., 1990; Erden , 2003 Difference between Type I DM and Type II DM Arkkila et al., 1997 Predictive value of Palm Print Test vs Mallampati, thyromental distance, and head extension Vani , Kamath , and Naik , 2000; George and Jacob, 2003 Sensitivity of Palm Print Test and Prayer Sign Sachdeva , 2013; Mahmoodpoor et al., 2013; Hashim and Thomas, 2014

12. Airway Assessment Palm Print Test Highly Sensitive 75%-98% Highly Specific 73%-96 % Prayer Sign Less sensitive 29.6%-54% Moderate-highly specific 55%-96%

13. Significance Problems in Anesthesia Unexpected difficult intubation Altered nerve monitoring Decreased lung elasticity

14. Summary Future research guiding practice Addition of tests to pre-operative assessment Inclusion of new knowledge into practice

15. References Arkkila , P., Kantola , I., & Viikari , J. (1997). Limited Joint Mobility in NonñInsulin Dependent Diabetic (NIDDM) Patients: Correlation to Control of Diabetes, Atherosclerotic Vascular Disease, and Other Diabetic Complications. Journal of Diabetes and Its Complications, 11.4 , 208-217. Retrieved August 11, 2015, from PubMed. Barash , P.G., Cullen, B.F., Stoelting , R.K., Cahalan , M.K., Stock, M.C., and Ortega, R. (2013). Clinical Anesthesia (7 th ed.). Philadelphia, PA: Lippincott, Williams & Wilkins and Wolters Kluwer Health. Erden , V. (2003). Relationship of difficult laryngoscopy to long-term non-insulin-dependent diabetes and hand abnormality detected using the 'prayer sign' British Journal of Anaesthesia , 159-160. doi:10.1093/ bja /aeg583 Fast Facts: Data and Statistics About Diabetes . American Diabetes Association, Mar. 2015. Web. 13 Aug. 2015. George, S.P., and Jacob, R. "Predictability of Airway Evaluation Indices in Diabetic Patients." Indian Journal of Anesthesia 47.6 (2003): 476-78. PubMed . Web. 11 Aug. 2015 Hines, R.L., and Marschall , K.E. (2012). Stoeltings Anesthesia and Co-Existing Disease (6 th ed.). Philadelphia, PA: Elsevier .

16. Hogan, K., Rusy , D., & Springman , S. (1988). Difficult Laryngoscopy and Diabetes Mellitus. Anesthesia & Analgesia, 67 , 1162-1165. Retrieved July 12, 2015, from PubMed.gov Infante , J., Rosenbloom , A., Silverstein, J., Garzarella , L., & Pollock, B. (2001). Changes in frequency and severity of limited joint mobility in children with type 1 diabetes mellitus between 1976-78 and 1998. The Journal of Pediatrics, 138 (1), 33-37. doi:10.1067/mpd.2001.109710 Kadoi , Y. (2010). Anesthetic considerations in diabetic patients. Part I: Preoperative considerations of patients with diabetes mellitus. Journal of Anesthesia. Japanese Society of Anesthesiologists , 24 , 739-747. doi:10.1007/s00540-010-0987-1 Larkin, M.E., Barnie , A., Braffett , B.H., Cleary, P.A., Diminick , L., Harth , J.,...(2014). Musculoskeletal Complications in Type 1 Diabetes. Diabetes Care 37.7, 1863-869. Retrieved August 11, 2015 from PubMed. Mahmoodpoor , Ata, Hassan Soleimanpour , Kavous Shahsavari Nia , Jafar Rahimi Panahi , Mohammadreza Afhami , Samad EJ Golzari , and Karim Majani . "Sensitivity of Palm Print, Modified Mallampati Score and 3-3-2 Rule in Prediction of Difficult Intubation." International Journal of Preventive Medicine 4.9 (2013): 1063-1069. PubMed . Web. 11 Aug. 2015 Nagelhout , J.J., and Plaus , K.L. (2014). Nurse Anesthesia (5 th ed.). Philadelphia, PA: Elsevier .

17. Reissell , E., R. Orko , E-L. Maunuksela , and Lindgren, L. "Predictability of Difficult Laryngoscopy in Patients with Long-term Diabetes Mellitus." Anaesthesia 45.12 (1990): 1024-027. PubMed . Web. 11 Aug. 2015. Sachdeva , K., Singh, A., Kathuria , S., Kaul , T., Rupinder , M., Bajwa , N., & Singh, P. (2005). Prediction of Difficult Laryngoscopy in Diabetics by Palm Print and Interphalangeal Gap. Journal of Anesthesiology Clinical Pharmacology, 21 (3), 261-264. Retrieved August 14, 2015, from PubMed.gov Salzarulo , H., & Taylor, L. (1986). Diabetic ìStiff Joint Syndromeî as a Cause of Difficult Endotracheal Intubation. Anesthesiology, 64 , 366-367. Retrieved July 20, 2015, from PubMed.gov Silverstein, J., Gordon, G., Pollock, B., & Rosenbloom , A. (1998). Long-term glycemic control influences the onset of limited joint mobility in type 1 diabetes. The Journal of Pediatrics, 132 (6), 944-947. Retrieved July 16, 2015, from PubMed.gov Thomas, M., and Hashim , K.Y. "Sensitivity of Palm Print Sign in Prediction of Difficult Laryngoscopy in Diabetes: A Comparison with Other Airway Indices." Indian Journal of Anaesthesia Indian J Anaesth 58.3 (2014): 298-302. PubMed . Web. 11 Aug. 2015. Vani V V, Kamath S K, Naik L D. The palm print as a sensitive predictor of difficult laryngoscopy in diabetics: a comparison with other airway evaluation indices. J Postgrad Med 2000;46: 75