Diabetes Mellitus

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Diabetes Mellitus Anesthetic Implications,
Including Perioperative Glycemic Control

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outline

• Definition, diagnosis classification
• Pre op systematic evaluation
• Over view of anesthetic techniques
• Pharmacology of insulin OHA
• Peri op glycemic control

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Definition ( WHO)

• Diabetes mellitus -
• A metabolic disorder of multiple etiology
  characterized
• by chronic hyperglycemia with disturbances
  of
• carbohydrate, fat and protein metabolism
• resulting from defects in insulin secretion,
  insulin action
• or both.

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Classification, Pathophysiology and Prevalence of
DM (WHO / ADA)
Class Pathogenesis Prevalence
Type 1 (Formerly juvenile or IDDM) Immune mediated idiopathic forms of ß cell function absolute insulin deficiency 0.4 male female usually young
Type 2 (Formerly NIDDM) Insulin resistance relative insulin deficiency or secretory defect 6.6 adult onset
Type 3 Specific types of DM genetic defect / disease of exocrine pancreas
Type 4 Gestational DM 4 of pregnancies
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Revised diagnostic criteria for diabetes
mellitus
Diabetic range mmol / l (mg) Diabetic range mmol / l (mg) IFG Further test
FPG RPG FPG Further test
ADA 2004 gt 7 (126) gt 11.1 ( 200) 6.1 7 (100 - lt126 ) Rpt in a different day
WHO 1998 gt 7 (126) gt 11.1 (200) 6.1 7 (110 - lt126 ) 2nd FPG (or) OGT
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Preoperative evaluation risk assessment

• Classical diabetic complications
• Macroangiopathy -
  arteriosclerosis
• Microangiopathy - heart, kidney
  retina
• Autonomic neuropathy - heart,GI urinary
  tracts
• Collagen anomalies - respiratory
  tract joints
• Unifying hypothesis - impaired glycosylation of
  proteins
• Systematic search of diabetic complications - key
  step

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Cardio vascular risk assessment

• Major disturbances
• Coronary artery disease
• Arterial HTN
• Impaired LV function
• Cardiac dysautonomy
• Sudden death

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Diabetic coronary artery disease

• Intermediate clinical predictor (ACC/AHA)
• Cardiac event rate - 2.5 / year
• 2 fold increased in mortality
• Silent ischemia
• Screening asymptomatic patients ? ?
• appropriate for high risk
  patients.

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Systemic Arterial HTN

• Incidence - 29 -54
• Mechanism
• stage 1 - angiotensin II mediated
• stage 2 - impaired glycosylation
• stage 3 - nephropathy
• Management - CCB, ACE inhibitors and
• Alpha adr
  blocking drugs

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Cardiac autonomic neuropathy (CAN)

• Degeneration of afferent and efferent nerve
  fibers of SNSPSNS
• Independent of age, duration of diabetes and
  severity of micro vascular complications
• Impaired cardio vascular response to exercise and
  stress

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Cardiac autonomic neuropathy (CAN)

• Increased cardiac morbidity
• Hemodynamic instability - impaired
  baroreflex
• Painless myocardial ischemia and
  infarction
• Dysrhythmias - VF
• Cardio respiratory arrest
• BJA 1993 71 258 261
• .Anesthesiology 1994 80326 337
• .Anesth analg 199388989 -991

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Autonomic neuropathy

• 20 - 40 of diabetics
• Influence anesthetic plan
• Clinical predictors
• Prayer sign
• Peripheral neuropathy
• History
• loss of sweating
• early satiety

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Diabetic dysautonomic neuropathy scoring
Tests Results Scores
Sys BP decrease in upright position (mmhg) lt10 11 29 gt30 0 ½ 1
R-R intervals ratio in upright position gt1.04 1.01 -1.03 lt1.00 0 ½ 1
Diastolic BP increase during hand grip test (mmhg) gt16 11-15 lt10 0 ½ 1
Respiratory dysrhythmias lt15 11-14 lt10 0 ½ 1
Valsalva quotient gt1.21 lt1.10 0 1
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Diabetic dysautonomic neuropathy scoring
Autonomic nervous system Scoring
Normal 0 - 0.5 Early change 1 - 1.5 Definitive modification 2 - 3.5 Severe impairment 4 - 5
Miller s Anesthesia, 6th ed Churchill Livingstone
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Temperature regulation Visceral neuropathy

• Risk of hypothermia - impaired vasoconstriction
• Anesthesiology 200092(5)1311 8
• Gastro paresis
• Due to vagal denervation
• Associated with esophageal dysmotility
• Reduced LES tone
• At risk of aspiration
• Anesth Analg 1994 79 943 47

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Neurological risk

• Peripheral neuropathy
• Mono poly
• 7.5 of type 2 DM
• 10-27increase in mortality
• Risk of nerve compression
• Preferable to avoid neural blocks in pre
  existing
• neuropathies

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Respiratory risk

• Impaired function even at early stage
• Higher plasma HbA1c level correlates significant
  Impairment
• Decrease in the reactivity to cough and
  ventilatory response to hypoxia and hypercapnia
• PFT reduced TV, FEV and Impaired DLco
• Loss of elastic properties and altered transport
  capacities

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Difficult intubation risk

• 33.2 of long standing type 1 DM
• Stiff joint syndrome - Rigidity of atlanto
  occipital joint,
• tight
  waxy skin ,non familial short
• stature
  and joint rigidity
• Prayer sign Palmer print sign
• Vagus recurrent laryngeal nerve neuropathy
• Difficult in laryngoscopy intubation combined
  risk of aspiration
• Ref Anesthesiology 1986 64 366 68
• Acta Anesth Scand 199842199 -203

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Renal risk

• Risk of ARF
• Major contributing factors
• Hemodynamic instability
• Decreased renal perfusion
• Urosepsis
• UTI - Most common post op
  complication
• Renal failure - Most frequent major
  complication
• incidence 7
• Microalbiminuria - Predicts general severity
  of DM
• Not a marker
  of renal failure

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Wound healing and infection

• Long known phenomenon
• Pre post operative glycemic control restore
  healing
• Continuous insulin infusion favors healing
• Higher rate of wound infection

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Basic lab investigations

• Fasting glucose
• Electrolytes
• BUN creatinine
• ECG

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Anesthetic agents and diabetes

• Induction agents
• Etomidate Blocks adrenal
  steroidogenesis
• BZD Stimulate GH
  secretion
• Propofol Reduced
  ability to clear lipids
• Inhalation agents
• Inhibit insulin action on
  glucose
• Short lived

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Regional anesthesia vs GA

• Epidural anesthesia blocks catecholamine
  release
• Caution - LA dose nerve injury
• Inhibition of stress by opioid limited to
  intraop period
• No evidence to support RA over GA
• Stable anesthesia - the goal
• Quality of anesthesia
• Schedule early in the day

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Out vs. In patient surgery

• Out patient if
• Evaluation of history in advance
• Prehydration
• Monitoring need
• No CNS ischemia
• Pregnancy
• Glucose monitoring
• Plan higher admit rate
• Look for red wound

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Insulin preparations and guidelines
Rapid- acting Insulin lispro (Humalog) Insulin apart (Novolog) Onset 5 -15 min Peak 60 -120min Duration 4 5 h
Short acting Regular insulin Onset 30 - 60 min Peak 2 - 4 h Duration 6 - 8 h
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Insulin preparations and guidelines
Intermediate acting NPH (neutral protamine Hagedorn) Lente Onset 1 -3 h Peak 4 - 6 h Duration 12 - 14 h Onset 1 -3 h Peak 4 - 8 h Duration 12 - 20h
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Insulin preparations and guidelines
Long acting Ultralente Glargine Onset 2 -4 h Peak 14 - 18 h Duration 18 - 24h Onset 1 -2 h Peak less Duration 20 - 24h
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Insulin preparations and guidelines
Premixed/combination insulin 70/3070NPH/30reg 50/5050NPH/50reg 75/25NPL/25lispro BBF BD Intermediate acting twice a day
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Oral Hypoglycemic Agents
Class Sulfonylurea Agents Duration Action Side-effects
1st generation Tolbutamide Chlorpropamide 6 -12 h 24 -72 h 6 -12 h Up to 24h Increased pancreatic insulin release Receptor level action Hypoglycemia
2nd generation Glipizide Giburaide Glimepride 6 -12 h 24 -72 h 6 -12 h Up to 24h Increased pancreatic insulin release Receptor level action Hypoglycemia
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Oral Hypoglycemic Agents
Class Agents Duration Action Side-effects
Biguanides Metformin 7 -12 h Up to 24h Improve receptor sensitivity ? Reduction in resistance Pancreatic insulin release Lactic acidosis Liver dysfunction
Glitizones Tro Rosi Pio Dar 7 -12 h Up to 24h Improve receptor sensitivity ? Reduction in resistance Pancreatic insulin release Lactic acidosis Liver dysfunction
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Oral Hypoglycemic Agents
Class Agents Duration Action Side-effects
Glinides Repaglinide Nateglinide 3 h 4 h Rapid insulin secretion Reduced carbohydrate absorption Liver dysfn Diarrhea Abd pain
Alpha glucosidase inhibitor acarbose 3 h 4 h Rapid insulin secretion Reduced carbohydrate absorption Liver dysfn Diarrhea Abd pain
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