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DIABETES MELLITUS IN ANAESTHESIA
SHARANIA MANIVANNAN
11 2014 182
ABSTRACT
Anaesthesiologists frequently encounter patients
with diseases of the endocrine system, in particular
diabetes mellitus. The major risk factors for people
with diabetes undergoing surgery are the associated
end-organ diseases: cardiovascular autonomic
neuropathy, joint collagen tissue, and immune
deficiency.
INTRODUCTION
Patients with diabetes have a significantly
increased risk of premature mortality and an
increased risk of microvascular and cardiovascular
complications and are often sicker than most non-
diabetic patients and therefore place a
proportionally larger burden on anaesthetic
services.
INTRODUCTION
Major risk
factor
Cardiovascular dysfunction
Renal insufficiency
Joint stiffness
Neuropathies
ANAESTHETIC AGENTS AND DIABETES MELLITUS
Affect glucose homeostasis peri-operatively by decreasing catabolic hormone secretion
Use of succinylcholine should be avoided if patients have elevated baseline serum potassium concentrations
Infusions of midazolam shown to decrease ACTH and cortisol secretion
Benzodiazepines reduce SS but increase growth hormone secretion, resulting in decrease in the hyperglycaemic response to surgery.
Morphine needs to be reduced to 75% of the standard dose in patients with a GFR of 10–50 ml/min, and 50% in patients with a GFR < 10 ml/min
ANAESTHETIC AGENTS AND DIABETES MELLITUS
Fentanyl is primarily metabolised in the liver by CYP3A4, making it an attractive choice for patients with renal dysfunction.
Premedication with clonidine in DM 2 90 minutes before surgery improved blood glucose control hence decreasing insulin requirement.
Halothane and sevoflurane, produce greater negative inotropic effects in diabetic patients than in non-diabetic patients.
ANAESTHETIC TECHNIQUES
Spinal, epidural or other regional blockade
modulate the secretion of catabolic
hormones and insulin secretion.
No evidence suggests that one anaesthetic
technique or another affects mortality or
morbidity in diabetic patients.
SPINAL ANAESTHESIA
REGIONAL ANAESTHESIA
Advantages
Allow patient to remain conscious and decrease surgical stress response
Decreases blood loss and leads to a decreased risk
of thromboembolism.
Disadvantages
Cardiovascular instability
Exacerbation of peripheral neuropathy since diabetic patients more susceptible
to anaesthetic toxidity
BLOCK OF THE DEEP PERONEAL NERVEAlong the imaginary line - between the medial and lateral malleolus, feel for tendons of the anterior tibialis and extensor hallucis longus muscle. The muscle tendon can be easily palpated if the patient is asks to dorsiflex his/her foot. Insert the needle between the two tendons with the point of the needle towards the tibia. A loss of resistance should be detected as the needle pierces the flexor retinaculum, inject 5 ml of 0.5-1% lidoocaine with adrenaline
PERIOPERATIVE MANAGEMENT
It is generally recommended to aim for
normoglycaemia in hospitalised patients.
The main concern of the anaesthesiologist in
the peri-operative management of diabetic
patients has always been the avoidance of
harmful hypoglycaemia; made more difficult
by the reduced level of consciousness
masking its signs and symptoms.
PERIOPERATIVE MANAGEMENT
Glucose levels > 200 mg/dL are considered
detrimental and require treatment.
It is important to exclude diabetic
ketoacidosis and non-ketotic hyperglycaemic
hyperosmolar states in patients presenting
with very high glucose levels; surgery in the
presence of such conditions carries a high
mortality.
SUMMARY
Endocrine disorders should be identified and
evaluated before surgery. Diabetes affects
multiple organ systems, and the peri-
operative effects of diabetes can be
profound. Peri-operative management should
be based on the type of diabetes, end organ
dysfunction and the desired degree of
glucose control in the peri-operative periods.