diabetes mellitus and its anesthesia management management of DkA, complication of Dm and its implication on anesthesia management

1. Presented by :HAIDER ZAMAN
KMU-IPMS
Thursday,
June
1,
2023
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2.  Diabetes mellitus is a clinical syndrome
characterized by chronic hyperglycemia and
disturbance in carbohydrate metabolism
 The disease may result from defect in insulin
secretion or an adequate tissue responce to insulin
 This leads to increased circulating glucose levels
with eventual microvascular and macrovascular
complication
Thursday,
June
1,
2023
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3.  Insulin is secreted by β cells in the islets of
langerhans of pancreas.
 Insulin is polypeptide with 51 amino acid.
 it has two amino acid chains called α and β chains
 Adults normally secrete approximately 50 units of
insuline each day.
 Rate of insulin secretion is primary determined by
the plasma glucose concentration
 Insulin the most important anabolic hormones, has
multiple metabolic effects.
Thursday,
June
1,
2023
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4.  Promotes glycogenesis
 Increase synthesis of
Triglcerides, cholestrol
and VLDL3
 Increase protein
Synthesis
 Inhibits glycogenolysis
 Inhibits ketogenesis
 Inhibits gluconeogensis
Thursday,
June
1,
2023
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5.  Incresae amino acid
transport
 Increase protein
sythesis
 Increase glucose
transport
 Enhance activity of
glycogen synthetase
 Inhibits activity of
glycogen
phosphorylase
Thursday,
June
1,
2023
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6.  Promotes triglycerides storage
 Induces lipoprotein lipase, making fatty acids
available for absorption into fat cells
 Increase glucose transport into fat cells
 Inhibits intracellular lipolysis
Thursday,
June
1,
2023
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7.  Primary diabetes mellitus
Type 1 diabetes
Type 2 diabetes
 Secondary diabetes mellitus
 a) Endocrine disease
cushing’s syndrome
Thyrotoxicosis
Pheochromocytosis
Acromegaly
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June
1,
2023
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8.  b)Pancreatic disease
Pancreatitis
Cystic fibrosis
Pancreactomy
Hemochromatosis
 c) Drug induced
Corticosteriods theraphy
Thiazide diruretics
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June
1,
2023
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9.  d)Gastational diabetes
Diabetes of pregnency
 e) Associated with genetic syndromes
Down’s syndrome
Turner’s syndrome
Myotonic dystrophy
Kilnefelter’s syndrome
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June
1,
2023
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10.  Also called insulin dependent diabetes mellitus
(IDDM) or Juvenile- onset diabetes
 Between 5% and 10% of all cases of diabetes are
type 1
 Type 1 diabetes result from autoimmune destuction
of the pancreatic islets β cell with absolute loss of
insulin secreation
 Type 1 diabetes is commonly presents in childhood
and adolescence
Thursday,
June
1,
2023
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11.  Type 1 diabetes is caused by T-cell mediated
autoimmune distruction of β-cell in the pancrease.
 The exact cause is unkown,althoug
 Genetic susceptibility
 Inheritance
 human leukocyte antigen (HLA) system
 Viral infecton
 Pancreatic pathology
 Immunological factor
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June
1,
2023
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12.  Its include 90-95% of those with diabetes
 Term used previously include non-insulin depended
diabetes and adult or maturity onset diabetes
 These patients have insulin resistance and usually
have relative insulin defiency
 Most do not need insulin treatment for their survival
 Type 2 diabetes usually manifests above 30 years
Thursday,
June
1,
2023
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13.  Exact cause unknown
 Genetics
 Environmental factor
life style: overeating especially when combine
with obesity probably act as a diabetogenic factor
 Pancreatic pathology
Reduction of insulin secretion cells
Resistance to insulin action
Delayed insulin secretion in response to oral
glucose
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June
1,
2023
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14. Thursday,
June
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 Polyuria
 polydipsia
 Weight loss
 Blurring of vision
 Postural hypotension
 Paraethesia
 Polyphagia
 Ketoacidosis
 Asymptomatic initally
 Polyuria
 polydipsia
 Delay wound healing
 Visual blurring
 Pruritus
 Peripheral neuropathy
Type 1 diabetes mellitus Type 2 diabetes mellitus

15. Pathophysiology of GDM:
 In early pregnency maternal estrogen and
progesterone increase and promote pancreatic β-
cells and increased insulin release
 Increase in peripheral glucose utilization and
glycogen storage
 As pregnancy progress increased level of human
chorionic somatomammotropin (HCS), cortisol,
prolactin, progesterone, and estrogen and leads to
insulin resistance in peripheral tissues
 The pancrease release 1.5-2.5 times more insulin
in order to respond to insulin resistance
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June
1,
2023
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16.  GDM result when there is delayed or insufficient
insulin secreation in the presence of increasing
peripheral resistance
 Independed risk factor for gastational diabetes :
 Body mass index above 30 kg/m
 Previous gastational diabetes
 Family history of diabetes
 Previous macrosomic baby weight 4.5 kg or
above
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June
1,
2023
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17. White classification, named after priscilla white who
pioneered research on the effects of diabetes types
on perinatal outcome is widely used to assess
maternal and fetal risk.
 Gastational diabetes (diabetes which began during
pregnancy)
 Pregastational diabetes (diabetes that existed prior
to pregnancy)
 There are 2 subtype of gastational diabetes
 Type A1:
 Type A2
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June
1,
2023
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18. Thursday,
June
1,
2023
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19. 1. Macrovascular (coronary artery disease, peripheral
arterial disease and stroke)
Mechanism of injury
o Atherosclerosis
o increased coagulability and impaired fibrinolysis
2. Microvascular complicataion ( diabetic nephropathy,
neuropathy, and retinopathy)
Mechanism of injury
o osmotic stress from sorbirol accumulation
o formation of advanced glycosylated end products
o free redical production and O2 species formation
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June
1,
2023
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20. Diabetes nephropathy
Approximately 30_40% of individuals with type 1
diabetes and 5_10% of those with type 2 diabetes
develop end-stage renal disrease
Mechanism of injury
 Glomerular hyperfiltration
 Increase in glomerular hydrostatic pressure causes
glomerular deamge and microalbuminuria
 Impaired endothelium-depended vasodilation
 Earliest sign is microalbuminuria
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June
1,
2023
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21.  Diabetic neuropathy
 Chronic sensorimotor distal symmetric
polyneuropathy is the most common form
-most common symptoms are burning, tingling
and numbness
 Mononeuropathies are sudden onset. Median, ulnar
and radial commonly affected
 Diabetic neuropathy: severe pain and muscle
weakness and atrophy usually in thigh muscles
 Diabetic autonomic neuropathy (due to local
ischemia tissue accumulation of sarbitol and
immunological demage)
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June
1,
2023
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22. Diabetic retinopathy
 Dot hemorrhage, hard exudate, microaneurysms,
retinal edema
 Proliferative retinopathy and retinal detachment
Cardiac complication :
 Increased risk of coronary artery disease(slient)
 Hypertension
 Peripheral arterial disease
 Systolic and diastolic dysfunction (related to
hypertension, coronary artery disease, left
ventricular hypertroph,y autonomic neuropathy)
 Heart rate variability
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June
1,
2023
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23.  Central nervous system:
 Cerebral vascular disease related to
_Hypertension
_Dyslipidemia
_Accelerated atherosclerosis
_Abnormal endothelial proloferation
_Increased coagulabillity and impaired fibrinolysis
 Gastrointestinal system:
 Risk of aspiration is increased because of
autonomic neuropathy
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June
1,
2023
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24.  Respiratory system:
 Decreased lung volume and lung diffusing capacity
 Reduced hypoxic-induced ventilatory drive
 Diabetics may prone to respiratory depression from
opioids and sedative agent
 Airway difficulties
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June
1,
2023
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25.  The “stiff joint” or limited joint mobility (LJM) or
diabetic cheiroarthopathy
 Jonit supporting airway rigidity. Neck extension and
laryngoscopy may be difficult
 Cause: nonenzymatic glycosylation of proteins and
abnormal cross-linking of collagen in jionts and
other tissue
 Test:
 prayer sign”
 palm print test:
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June
1,
2023
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26. Thursday,
June
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2023
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27. Thursday,
June
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2023
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28.  There are three life-threating acute complication of
diabetes
 Diabetic ketoacidosis (DKA)
 Hyperosmolar hyperglycemic state
 Hypoglycemia
Thursday,
June
1,
2023
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29.  Diabetic ketoacidosis (DKA) is a complication of
decompensated diabetes mllitus.
 Seen in type 1 diabetes during the catabolic stress
of acute illness such as trauma, surgery, or
infection.
 Clinical feature are:
 Symptoms of hyperglycemia like polyuria and
polydipsia.
 Symptoms of acidosis and dehydration such as
respiratory distres, drowsiness, coma and
abdominal pain
 Other symptoms like vomiting, malaise, cramps
 Signs: include tachycardia, dehydration, acidosis,
depressed consiousness
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June
1,
2023
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30.  Mechanism:
 Increased gluconeogenesis and hepatic and renal
glucose production along with impaired glucose
utlization in peripheral tissue cause hyperglycemia
and hyperosmlality.
 The increase counter regulatory hormones lead to
lipolysis and hepatic fatty acid oxidation to ketone
bodies (hydroxybutyrate, actone and acetoacetate
acid) with resulting metabolic acidosis.
 Osmotic diuresis leads water loss and electrolyte
distrurbance.
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June
1,
2023
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31.  HHS is characterized by severe hyperglycemia,
hyperosmolarity and dehydration
 seen in the type 2 diabetics, more commonly in
elderly people with co existing disease.
 Caused by plasma insulin concentration that are
inadequate for glucose utilization but are adequate
to prevent lipolysis and ketogenesis
 The hyperglycemia and volume deficit is more
severe then DKA.
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June
1,
2023
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32. Hyperosmolar nonketotic coma or(HHS)
 Clinical features:
 polyuria, polydipsia,
 Slow onset over days to weeks.
 Symptoms of hyperglycemia.
 Sign of dehydration.
 Sign of hyper viscosity and thrombosis like delirium
, coma, seizures, sensory and motor deficits.
 Abdominal pain is unusual. Vomiting may be
present.
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June
1,
2023
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33.  Principle of treatment of DKA and HHS
 1) correction of dehydration, hyperglycemia, and
electrolyte imbalances
 2) identification of comorbid precipitating events
 3) freqent patient monitring
 Fluid therapy:
 15-20 mL/kg body weight of 0.9% NACL is infused
in the first hour.
 Further fluid resuscitation is guided by assignment
of fluid status, urine output and electrolytes level.
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June
1,
2023
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34.  0.5% or 0.9% NACL may be used.
 Total fluid deficit is corrected over 24 hours with
constant monitoring to avoid overload.
 Patients in hemodynamic shock need fluid and
vasopressor therapy with advanced hemodynamic
monitoring.
 Patients with pre existing cardiac dysfunction need
cautious fluid boluses.
Thursday,
June
1,
2023
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35.  Insulin therapy:
 I/v bolus of regular insulin 0.1 unit/k body wt.
 Followed by a continuous infusion at a dose of 0.1
unit/kg/hr should be administered with the aim to
decrease plasma glucose concentration at a rate of
50-75 mg % per hour.
 If the drop is not adequate, insulin dose can be
doubled to achieve steady drop.
 Potassium theraphy:
 Serum potassium < 3.3 mEq/l supplement
potassium at 20-30mEq/h before starting insuln to
aviod arythmias, cardiac arrest or respiratory
muscle weakness.
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June
1,
2023
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36.  Bicarbonate:
 Bicarbonate is usually reserved for severe metabolic
acidosis with pH < 7.0.
 50 or100 mmoL bicarbonate can be given depending on
the severity of acidosis,
 Bicarbonates should not be used in presence of
hypokalemia till serum potassium levels are corrected.
 Phosphate:
 Supplementation is advised only at serum phosphate
concentration < 1.0 mg/dl or in the presence of anemia,
cardiac dysfunction or respiratory muscle weakness. If
needed, 20-30 mEa/L potassium phosphate can be
given.
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June
1,
2023
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37.  Monitring:
 2-4 hourly estimation of serum electrolytes,
glucose, blood urea nitrogen, creatinine, osmolality
and acid status.
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June
1,
2023
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38.  Hypoglycemia in the diabetic patient is the result of
an absolute or relative excess of insulin relative to
carbohydrate intake and exercise.
 If hypoglycemia is not treated, mental status
changes can progress from anxity,
lightheadedness, or confusion and coma
 The treatment of hypoglycemia in anesthetized or
critically ill patients consist of intravenous
administration of 50% glucose
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June
1,
2023
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39.  Timing
 Fasting
 IV fluid
 Monitoring
 Standard monitoring
 Glycosylated hemoglobin (HbAc)
 Sugar control
 Glucose supplement
 Insulin supplement
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June
1,
2023
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40.  History:
 which oral hypoglycemic agents
 If insulin type of insulin and dosing schedule
 Disease history
 Complication history
 Physical examination
 Cvs examination
 Respiratory system examination
 CNS examination
 Airway examination
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June
1,
2023
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41.  Investigation
 Hemoglobin: anemia is present with renal
dysfunction
 CBC : look for infection
 Urine routine for microalbuminuria
 Serum creatnine: to detect renal function
 Fasting blood sugar:
 Glycosylated Hb:HbA1c of less then 7% implies
good sugar control
 Serum electrolyte: to detect abnormalities in
patient with history of vomiting, diarrhea, poor oral
intake. Also in patient on insulin
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June
1,
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42.  Investigation
 ECG: To detect asymptomatic myocardial
infarction. DM patient have increased incidence of
ST-segment and T-wave segment changes on ECG
 X-ray chest: tuberculosis is common is diabetic.
Cardiac enlargement, and pulmonary vascular
congestion, or plural effusion.
 Morning of surgery investigation:
 Serum electrolyte, FBS, urine ketones
 Emergency surgery:
 Need full clinical and biochemical assessment.
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June
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2023
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43.  Reflex dysfunction of the ANS may be increased by
old age, diabetes longer then 10 year’s duration,
coronary artery disesae
 Delay gastric emptying time
 Premedication with antacid and medclompramide is
often used.
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June
1,
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44.  lnduction:
 Choice of agent for general anesthesia depends on
severity of systemic diseases, such as coronary artery
disease, nephropathy, hypertension and autonomic
neuropathy.
 Epidural analgesia may be instituted after due
consideration to autonomic neuropathy, IHD and
peripheral neuropathy.
 It should be avoided in sick patients with sepsis.
 Epidural analgesia may help to attenuate
neurohormonal response to stress and avoid systemic
analgesics like NSAIDs and opioids which may have
serious side effects in a diabetic patient.

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June
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45.  A rapid sequence induction should be performed for
patients with GI symptoms.
 Awake fiberoptic bronchoscopy would be preferred
technique for an anticipated diffiCUIt airway.
 A careful induction with Etomidate or high dose
Fentanyl (4-5 mcg/kg) with midazolam and/or
thiopentone should be performed (exaggerated
hypotension due to autonomic neuropathy)
 Succinylcholine should be avioded
 Rocuronium may be used in RSI
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June
1,
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46.  Maintenance of anesthesia:
 Isoflurane and sevoflurane can be used
 Nitrous oxide should be avoided
 Airway pressure should be monitered
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June
1,
2023
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47.  Induction agent:
 Ketamine may cause significant hyperglycemia.
 Etomidate blocks adrenal steroidogenesis and
hence gortisol synthesis and decreases the
hyperglycemlc response to surgery by
apptoximately 18 mg% in non-diabetic subjects
 The effect of popofol on insulin secretion is not
known
 Halothane, enflurane, isoflurane and sevoflurane in
in vitro studies inhibit the insulin response to
glucose in a reversible and dose-dependent
manner but their effect in clinical situations is not
certain
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June
1,
2023
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48.  Benzodiazepines decrease the secretion of ACTH
and the production of cortisol, when used in high
doses.
 High-dose opiate anesthetic techniques produce
hemodynamic, hormonal and metabolic stability
 Ganglion-blocking agents (used for hypotensive
anesthesia prviously) may block sympametically
mediated hepatic gluconeogenesis with resultant
hypoglycemia
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June
1,
2023
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49.  The goal of intraoperative blood glucose
management is to avoid hypoglycemia while
mantaning blood sugar blow 180 mg/dL
 Hyperglycemia is has been associated with
hyperosmolarity, infection, poor wound healing and
increased mortilty
 Loose control (<180 mg/dL)
 Tight control (<150 mg/dL)
 Control of blood glucose in pregnant diabetic
patients improves fetal outcome.
 There are several common perioperative
management regmens for insulin-depended
diabetic patients
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June
1,
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50.  In the most time-honored (but not terribly effective)
approach, the patient receives a fraction-usually
half-of the total morning insulin dose in the form of
intermediate-acting insulin
 To decrease the risk of hypoglycemia. insulin is
administered after intravenous access has been
established and the morning blood glucose
 An alternative method is to administer regular
insulin as a continuous infusion.
 Regular insulin can be added to normal saline in a
concentration of 1 unit/mL and the infusion begun at
0.1 unit/kg/h.
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June
1,
2023
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51.  the regular insulin infusion can be adjusted up or down
as required.
 The dose required may be approximated by the
following formula:
 Unit per hour = Plasma glucose (mg/dL) /150
 When administering an intravenous insulin infusion to
surgical patients, adding some (eg, 20 mEq) KCl to each
liter of fluid may be useful, as insulin causes an
intracellular potassium shift.
 The key to any management regimen is to monitor
plasma glucose levels frequently.
 Patients receiving insulin infusions intraoperatively may
need to have their glucose measured hourly.
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June
1,
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52.  Patients who take NPH(neutral protamine
hagedorn) or other protamine containing insulin
preparations have an increased risk of allergies
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June
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2023
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53.  “tight sugar control” refers to maintaince of blood
sugar within narrow range, typically between 70-
110 mg%
 Hypoglycemia is a significant risk in this approach
 Significant in cardiac surgery, neuronal injury,
burns, transplant surgery, critically ill paitents and
pregnant women.
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54.  Close monitoring of blood sugar
 And multimodal analgesic technique
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