Anesthesia for Diabetic Patients

7/28/2019 Anesthesia for Diabetic Patients

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Anamnesa:

Difokuskan pada masalah utama yg

berhubungan dengan tindakan anestesi dan

pembedahan.

DM tipe 2

RA

Penggunaan Steroid

Sulit intubasi


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DM tipe 2

Lama penyakit

Riwayat terapi

Adekuat kontrol gula darah Komplikasi


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Rheumatoid Arthritis

Lama Penyakit

Sendi2 yang terkena

Terapi Komplikasi: CV & Respirasi?


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Perioperative Care of theDiabetic Patient

Erwin Pradian

Bagian Anestesiologi dan ReanimasiFakultas Kedokteran Universitas Padjadjaran

RS. Dr. Hasan Sadikin Bandung


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Perioperative care of

diabetic patient Focus Preoperative history

Physical examination : asses end-organ disease

Appropriate intervention

Potential disorder

Coronary artery dis., cardiomyopathy, hypertention, renalinsufficiency, peripheral vascular dis., infection, stiff joint syndrom,

peripheral and autonomic neuropathy, large territory stroke, smallvessel ischemic dis., retinopathy

Life-threatening metabolic derangement Severe hypoglycemia, diabetic ketoacidosis, nonketotic

hyperosmolar state


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Cardiomyopathy

Prolonged ACE inhibitor

Reduce stroked, MI, death in diabetes patient

By reduced afterload

Diabetic cardiomyopathy

Patient without hypertension and coronary dis.

Related to microvascular change secondary to diabetes

Beta-blocker or calcium channel blocker

Decrease heart rate, suppress myocardial function,enhance diastolic relaxation


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Hypertension - CVA

Severe hypertension(>180/105 mmHg) Increase risk of MI or stroke

If untreated

BP : labile in perioperative period

Maintained within 20% of baseline value

Inadequately treated hypertension Higher mean arterial pressure

provide adequate organ perfusion

Cardiac and antihypertensive drug

Be continued throughout perioperative period

Exception : aspirin, diuretics, anticoagulants


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Renal disease ( I )

Hypergylcemia control

Avoid osmotic diuresis, prerenal azotemia, long-termprogression of glomerular injury

Nephrotoxic drug and dyes is avoided

Metformin : potential for lactic acidosis

Glyburide : only sulfonylurea excreted partially in bile

Low-dose dopamine, mannitol, diuretics

Administration during perioperative period renal protection?

But effectiveness is debatable


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Renal disease ( II )

Desmopressin acetate and cryoprecipitate

Improve coagulopathy associated with renal failure

ACE inhibitor

Creatinine concentration >3.0 mg/dl or creatinine clearance


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Peripheral Vascular Disease

Type I diabetes

Predominate microvascular complication

Retinopathy, neuropathy, nephropathy

Type II diabetes

Predominate macrovascular complication

Large vessel such as coronary or cerebral vessel

Complication

Foot ulcer amputation

Prevention maintainance of adequate hydration

limitation of vasoconstriction

attention to patient position

evaluation for arterial catheter


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Infection

Elevated glucose

Decrease leukocyte chemotaxis and function

Avoid delayed wound healing and

wound infection

Blood glucose concentration : not exceed 250

mg/dl

Strict sterile technique

Asymptomatic despite significant infection


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Stiff Joint Syndrome

Long-standing type I diabetes

Joint rigidity : temporomandibular

atlanto-occipital

cervical spine

Short stature

Tight, waxy skin

Limited neck mobility

Result in difficult intubation

Identified before airway manipulation Prayer sign

Denote stiff joint syndrome

indicate difficult intubation


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Peripheral Neuropathy

Increased susceptibility to soft tissue ischemia

Secondary to microvascular disease and peripheral

nerve injury

Pressure point : padded extensively

Local anesthetics

injected into area of marginal blood supply

epinephrine is avoided


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Laboratory Evaluation

Preoperative assessment Blood glucose, blood urea nitrogen, creatinine, ECG

Renal insufficiency

Electrolyte is evaluated

Elevated potassium amd magnesium arrhythmias

DKA ABGA and beta-hydroxy butyrate concentration

indicate level of acidosis and ketosis

Hg A1C Less than 8% indicate good glucose control

Increase indicate poor control and difficult intraoperativenormoglycemia


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Anesthetic Management

First operative case of the day

Metabolic abnormality

Corrected before entering OR

Oral hypoglycemic agent, regular insulin

be held the day of surgery

Long-acting insulin

Administered in half usual dose

Stress hormone

Stimulate glycogenolysis and hyperglycemia

Glucose monitoring

Every 1 to 2 hours intraoperatively

Immediate postoperative period


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Hypoglycemia

Serum blood glucose concentration Less than 50 mg/dl

Manifestation

Confusion, irritability, fatigue, headache, somnolence Adrenergic response

restlessness, diaphoresis, tachycardia, hypertension, arrhythmias,angina

Prolonged severe hypoglycemia

Seizure, focal neurological damage, coma

Initial therapy Administration of 50 ml 50% dextrose

Blood glucose change is impossible to predict


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Hyperglycemia

Maximal glucose reabsorption threshold of kindey

180 mg/dl of serum blood glucose

If exceed, glycosuria

Elevated blood glucose

Hyperosmolarity hyperviscosity and thrombogenesis

Treatment

Initially lispro or regular insulin IV

Insulin infusion gradual decrease serum glucose

Regular insulin 1 unit

Decrease blood glucose 30 mg/dl in 70-kg patient


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Diabetic Ketoacidosis ( I )

Predisposing factor Infection, trauma, MI, inappropriate insulin therapy, hypovolemia,

stress response to surgery

Signs and symptoms

Dehydration( osmotic diuresis ), decreased oral intake, alteredmental status, Kussmauls breathing( deep, rapid repiration ), fruityacetone odor, nausea, vomiting, abdominal pain, generalizedweakness, hypothermia( acidosis-related vasodilation )

Volume deficit

Result in prerenal azotemia, acute tubular necrosis, hypotension

Total body deficit of potasssium, sodium, phosphate,magnesium


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Diabetic Ketoacidosis ( II )

Arterial and large-bore IV catheter Allow evaluation of electrolyte, hemodynamic monitoring, volume

resuscitation

1 liter NSgiven as bolus dose

and 250 to 500 ml/h is continued

Potassium, magnesium, phosphorus Be replaced as needed

Bicarbonate

Not be given routinely as acidosis

Initially 5 to 10 unit insulin : IV bolus

and then insulin infusion : NS Serum glucose decrease : no faster than 50 mg/dl/h

After blood glucose 250 mg/dl

Insulin infusion and other fluid : contain dextrose ( prevent cerebraledema )


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Nonketotic Hyperosmolar State

Predisposing factor Similar to DKA

Secondary to postoperative dialysis

IV hyperalimentation

Type 2 diabetes rather than type 1

Not acidotic and not display Kussmaul breathing

Electrlyte deficit : less

Hyperglycemia, hyperosmolarity, dehydration

more profound

Neurologic symptoms more prominent with confusion, seizure, coma, focal deficits

Most important goal

aggressive fluid resuscitation

Insulin infusion : usually not needed


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Conclusion Most common endocrinopathy

Despite advances in diagnosis and therapy

Increased risk for complication related primary to vascular disease

Tighter glycemic control

Blunt development of microvascular disease

Safe perioperative period for all diabetic patient

Attention to glycemic control

Correction of metabolic derangement

Anticipation of potential complications


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Anesthesia for Diabetic Patients

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