diabetes presentation rakesh kumar

Diabetes Mellitus:Diabetes Mellitus: Three situations Three situations

Love & Best Wishes to the young friendsLove & Best Wishes to the young friendsRakesh Kumar, DA, MDRakesh Kumar, DA, MD

ProfessorProfessor

Anesthesiology, Intensive Care & Perioperative MedicineAnesthesiology, Intensive Care & Perioperative MedicineMAMC & Associated Hospitals, New DelhiMAMC & Associated Hospitals, New Delhi

What are the diagnostic yardsticks What are the diagnostic yardsticks for DM?for DM?

What is impaired fasting glycemia?What is impaired fasting glycemia? A BS of 180 mg.dlA BS of 180 mg.dl-1-1=How many =How many

mmol.Lmmol.L-1-1?? If venous BS is 110 mg.dlIf venous BS is 110 mg.dl-1-1, what is , what is

capillary BS?capillary BS?

Reproducible demonstration of fasting Reproducible demonstration of fasting hyperglycemia: FBS > 110 mg% (6.1 mmol Lhyperglycemia: FBS > 110 mg% (6.1 mmol L-1-1) ) (Serum/plasma sugar > 126 mg% [7 mmol L(Serum/plasma sugar > 126 mg% [7 mmol L-1-1, , OROR

A ‘casual’ (R) BS of > 180 mg% [10 mmol LA ‘casual’ (R) BS of > 180 mg% [10 mmol L-1-1], ], OR OR

Oral GTT producing a result in the diabetic Oral GTT producing a result in the diabetic range. range.

BS concentrations between 100 – 110 mg% BS concentrations between 100 – 110 mg% (5.6-6.1 mmol L(5.6-6.1 mmol L-1-1) ) ‘impaired fasting ‘impaired fasting glycemia’. glycemia’.

What are the factors What are the factors affecting the perioperative affecting the perioperative anesthetic management of anesthetic management of

DM?DM?

Type of DMType of DM MedicationMedication End-organ changes End-organ changes Nature of surgery Nature of surgery Urgency of surgeryUrgency of surgery Level of glycemic control Level of glycemic control

Case 1Case 1

60 year old, 60 kg man, height 60 year old, 60 kg man, height 165 cm; scheduled for 165 cm; scheduled for abdominoperineal resection of abdominoperineal resection of Ca. rectumCa. rectum

Known diabeticKnown diabetic BG: (F) = 120, (PP) = 170 mg.dlBG: (F) = 120, (PP) = 170 mg.dl-1-1

What would you want to find out from history, examination and investigations?

Treatment historyTreatment history

Two main categories of drugs?Two main categories of drugs?

What are their subdivisions?What are their subdivisions?

InsulinsInsulins

Preparation Type Onset(hrs)

Peak(hrs)

Duration(hrs)

Conventional (standard)

[Contain ≥ 1% i.e. 10,000 ppm of other proteins (proinsulin, proteins, insulin derivatives etc.)]

Short actingRegular (soluble) Insulin

Prompt Insulin Zinc Suspension (amorphous) or semilente

0.5 -1

1

2-4

3-6

6-8

12-16

Intermediate actingInsulin Zinc Suspension or Lente

(Ultra: Semi=7:3)Neutral Protamine Hagedorn (NPH)

or Isophane Insulin

1-2

1-2

8-10

8-10

20-24

20-24

Long actingExtended Insulin Zinc Suspension

(Crystalline) or UltralenteProtamine Zinc Insulin (PZI)

4-6

4-6

14-18

14-20

24-36

24-36

Insulins (contd..)Insulins (contd..)More Purified (Purified pork insulin-proinsulin <20-200ppm)

Single peak insulins(Proinsulin=50-200 ppm)Actrapid, Rapidica (=Regular insulin)Lentard, Zinulin (=Lente insulin)Actraphane, Rapimix (=Regular 30% + Isophane 70%)

0.5 -11-21-2

2-48-108-10

82224

Monocomponent (MC) insulins(Proinsulin<20 ppm)Actrapid MC (=MC Regular)Monotard MC (= MC Lente)

0.5 -11-2

2-48-10

822

Human Insulins

Human Actrapid (=human Regular)Human Monotard (=human Lente)Human Actraphane (=human soluble 30% + human Isophane 70%)Lispro (human recombinant)

0.5 -11-21-2

¼ - ½

2-48-108-10

1-2

82224

4-6

Oral antihyperglycemic Oral antihyperglycemic drugsdrugs

Drug Preparations Duration Remarks

Sulfonylureas 1st generation

- Tolbutamide

- Chlorpropamide

2nd generation- Glibenclamide

- Glipizide

- Gliclazide- Glimepiride

RASTINONARTOSINDIABINESEDIABIGON

DAONILEUGLUCONBETANASEGLYNASEMINIDIABDIAMICRONAMARYLGLYMER

6-8h

36-48h

18-24h

12-18h

12-24h12-24h

1. Increase pancreatic release of endogenous insulin and insulin receptor function

2. Cause hypoglycemia3. Glimepiride has

stronger extra pancreatic action through translocation of GLUT4 to plasma membrane & thus less chance of hypoglycemia

Biguanides Metformin Phenformin

GLYCIPHAGEDBI, DBI-TD

3-4 h1.? improves insulin

receptor functions2. Lactic acidosis (very rarely with metformin

Glinides-Repaglinide -Natglinide

PRANDIN 4-6hStimulate rapid insulin secretion (early peak without inter-prandial rise) by closing the ATP dependent potassium channel.

α-glucosidase inhibitors - Acarbose GLUCOBAY

PRECOSE

1. Decrease digestion,& absorption of carbohydrates 2. May cause diarrhea, abdominal pain

Thiazolidinediones 1st generation

-Troglitazone2nd generation

-Pioglitazone-Rosiglitazone-Darglitazone

ACTOSEAVANDIA

>3-4 wks>3-4 wks

Reverse insulin resistance in liver, adipose tissue and skeletal muscle, possibly by raising the number of glucose transporters sensitization of target cells to insulin).Chance of hepato-toxicity.

Miscellaneous - Guargum DIATAID

Dietary fiber from Indian cluster bean ‘guar’. Mixed with food, it slows glucose absorption.

Oral antihyperglycemic drugs (Contd..)Oral antihyperglycemic drugs (Contd..)

http://www.aventispharmaindia.com/presskitsDaonil.htm

Standard of BS ControlStandard of BS Control NephropathyNephropathy Ischemic heart disease, CHF and Ischemic heart disease, CHF and

CardiomyopathyCardiomyopathy Autonomic neuropathyAutonomic neuropathy RetinopathyRetinopathy Stiff joint syndromeStiff joint syndrome Electrolyte & metabolic Electrolyte & metabolic

derangementderangement

To Assess History and Examination Investigation

Standard of BS Control

- Hyper/Hypoglycemic episodes- Medication and Compliance

- BS (fasting, PP)- GTT (if required)- Glycosylated Hb (HbA1c)

To Assess History and Examination

Investigation

Nephropathy - H/o hypertension, swelling of face and body

- Hypertension and its medication

- Urine – Proteins Sugar

- Microalbuminuria on a timed overnight collection.

- B. Urea, S. Creatinine, S. Electrolytes irrespective of age.


Ischemic heart disease, CHF and Cardiomyopathy

- Angina or MI- Breathlessness,

swelling of feet- Poor exercise tolerance- Edema feet, enlarged

liver, raised JVP, basal crepts, S3/S4

- ECG- X-ray Chest


Autonomic neuropathy

- Early satiety, lack of sweating- Gastroparesis in the form of

vomiting, nocturnal diarrhea, abdominal distension.

- Orthostatic hypotension- Bladder atony and urinary

retention- Impotence- Palpitation- Sensory discomfort of lower limbs- Resting tachycardia- Irregular pulse- Dense peripheral neuropathy.

- Valsava: Ratio of the Longest R-R to the shortest R-R (N > 1.21)

- Beat-to-beat variation with deep breathing obtunded: Mean of (maximum HR – minimum HR) of 3 cycles of 6bpm (< 5bpm)

(N > 15 bpm) - HR response to

standing obtunded: Ratio of Longest R-R around 30th beat after standing to the Shortest R-R around 15th beat after standing (N > 1.04)

To Assess H / E Investigation

Autonomic neuropathy (continued)

- SBP response to standing: BP(lying) - BP(Standing) (>30 mm Hg) (N<10 mmHg)

- DBP response to sustained handgrip: Handgrip sustained at 30% of maximum squeeze for upto 5 minute & BP every minute. DBP just before release – Initial DBP. (N > 16 mmHg)


Investigation

Retinopathy - Vision deterioration

- Ophthalmologic examination


Investigation

Stiff joint syndrome

- Stiffness in hand joints- Inability to

approximate the palmar surfaces of phalangeal joints.

- “Prayer Sign”- Non-familial short

stature- Tight-waxy skin

- X-ray cervical spine to delineate limited atlantoaxial extension.


Investigation

Electrolyte & metabolic derangement

- Non-Compliance of drug

- Severe infection or starvation

- Poor control in the past few days/weeks

- S/S of hypoglycemia or ketoacidosis

- ABG and electrolytes

Case 1Case 1 60 year old, 60 kg man, height 165 60 year old, 60 kg man, height 165

cm; scheduled for cm; scheduled for abdominoperineal resection of Ca. abdominoperineal resection of Ca. rectumrectum

Known diabetic on Metformin and Known diabetic on Metformin and Glibenclimide, BD doseGlibenclimide, BD dose

Hypertension, CAD under checkHypertension, CAD under check BG: (F) = 120, (PP) = 170 mg.dlBG: (F) = 120, (PP) = 170 mg.dl-1-1

Switch over to insulin pre-op? Switch over to insulin pre-op? Pre-op orders?Pre-op orders?


cm; scheduled for abdominoperineal cm; scheduled for abdominoperineal resection of Ca. rectumresection of Ca. rectum



Morning BG=90; ½ h intra-op=150Morning BG=90; ½ h intra-op=150

Intra-op fluids and insulin?Intra-op fluids and insulin?

Patient’sForearm

Insulin (1U/mL)

Infusion Pump

D-5 (500 mL) + K+ 10mmol

N-Saline / Colloid / Blood

Patient’sForearm

Insulin (1U/60mL)

N-Saline (500 mL) + 8U insulin

D-5 (500 mL) + K+ 10mmol @ G=0.1g/kg/h

N-Saline / Colloid / Blood as required

NO INFUSION PUMP AVAILABLE

INFUSION PUMP AVAILABLE

Vellore regimen?Vellore regimen?

Miriam A and Korula G.Miriam A and Korula G. A Simple Glucose Insulin A Simple Glucose Insulin Regimen for Perioperative Blood Glucose Regimen for Perioperative Blood Glucose Control: The Vellore Regimen. Anesth Analg Control: The Vellore Regimen. Anesth Analg 2004;99:598-6022004;99:598-602 Intraoperative blood glucose control with 1 U of insulin for every Intraoperative blood glucose control with 1 U of insulin for every

1–50 mg of blood glucose value more than 100 mg/dL added to 1–50 mg of blood glucose value more than 100 mg/dL added to 100 mL of 5% dextrose in a measured volume set100 mL of 5% dextrose in a measured volume set

Hourly monitoring of blood glucoseHourly monitoring of blood glucose

Blood glucose control was compared with the different existing Blood glucose control was compared with the different existing techniques followed in the hospitaltechniques followed in the hospital

The study group had a mean ± SD blood glucose value of 156 ± The study group had a mean ± SD blood glucose value of 156 ± 36 mg/dL, and the control group’s value was 189 ± 63 mg/dL (36 mg/dL, and the control group’s value was 189 ± 63 mg/dL (PP = = 0.003)0.003)

Poorly controlled patients (<100 & >200-mg/dL) decreased from Poorly controlled patients (<100 & >200-mg/dL) decreased from 51% to 28% (no patient less than 60 mg/dL) compared with the 51% to 28% (no patient less than 60 mg/dL) compared with the control group in which it increased from 49% to 72% (10 patients control group in which it increased from 49% to 72% (10 patients less than 60 mg/dL) (less than 60 mg/dL) (PP = 0.0013) = 0.0013)

It is a simple and effective method and combines the advantages It is a simple and effective method and combines the advantages of combined glucose insulin and variable rate insulin infusion of combined glucose insulin and variable rate insulin infusion

Ringer’s lactate?Ringer’s lactate? Bank blood?Bank blood?

Fluid and volume replacementFluid and volume replacement Lactate and is a gluconeogenic substrateLactate and is a gluconeogenic substrate Ringer’s lactate = 28 meq/L Ringer’s lactate = 28 meq/L Bank blood = variable amounts (anaerobic Bank blood = variable amounts (anaerobic

metabolism during storage) metabolism during storage) Hepatic conversion to glucose Hepatic conversion to glucose aggravation aggravation

of stress-induced hyperglycemiaof stress-induced hyperglycemia Ringer’s lactate/Blood are NOT Ringer’s lactate/Blood are NOT

contraindicated but contraindicated but inappropriateinappropriate as as these can confound the calculation of these can confound the calculation of glucose load and insulin requirements glucose load and insulin requirements somewhatsomewhat


cm; scheduled for abdominoperineal cm; scheduled for abdominoperineal resection of Ca. rectumresection of Ca. rectum



Morning BG=90; ½ h intra-op=150Morning BG=90; ½ h intra-op=150

Epidural + GA planned; Epidural + GA planned;

Considerations during CN Blockade?Considerations during CN Blockade?

LA requirements lowerLA requirements lower

Risks of nerve injury higherRisks of nerve injury higher

Combination of LA with epinephrine may Combination of LA with epinephrine may pose greater risk of ischemic or pose greater risk of ischemic or edematous nerve injury (or both) in edematous nerve injury (or both) in diabeticdiabetic

Document peripheral neuropathy Document peripheral neuropathy keeps the patients and relatives informed keeps the patients and relatives informed avoids medico-legal hassles later on avoids medico-legal hassles later on

Insulin response to hyperglycemia Insulin response to hyperglycemia high thoracic (T1-T6) blockade high thoracic (T1-T6) blockade ? ? inhibited inhibited low blockade, (T9 - T12) low blockade, (T9 - T12) no effect no effect

Regional blocksRegional blocks

Case 2Case 2 40 year old, 45 kg lady40 year old, 45 kg lady Known diabetic on oral antihyperglycemicsKnown diabetic on oral antihyperglycemics High grade fever x 1wk, vomiting x till 2 High grade fever x 1wk, vomiting x till 2

days back, altered sensorium x 12 hdays back, altered sensorium x 12 h P=180 bpm, BP=70/40, BG=470 mg.dlP=180 bpm, BP=70/40, BG=470 mg.dl-1-1, , Blood Ketones (+++), pH=6.8, NaBlood Ketones (+++), pH=6.8, Na++-116, -116,

KK++- 3.4, HCO- 3.4, HCO33-10, P-10, PCO2CO2- 34, P- 34, PO2O2- 78 mmHg- 78 mmHg Emergency laparotomyEmergency laparotomy Yes/No? How quickly? What till then?Yes/No? How quickly? What till then?

Yes!Yes! 2-3 h may be enough 2-3 h may be enough

What are confounding factors in a What are confounding factors in a diabetic for emergency surgery?diabetic for emergency surgery?

Do we have to wait for the DKA to Do we have to wait for the DKA to settle before taking up the patient?settle before taking up the patient?

What are the indicators for going What are the indicators for going ahead with surgery?ahead with surgery?

At what pH do we need sodabicarb At what pH do we need sodabicarb correction; what before that?correction; what before that?

Role of insulin bolusRole of insulin bolus Any alteration in monitoring?Any alteration in monitoring? When to start KWhen to start K++, when glucose?, when glucose? DM with uncontrolled BS for semi-em DM with uncontrolled BS for semi-em

tomorrow; are you game? If yes, how; tomorrow; are you game? If yes, how; if no, why not?if no, why not?

Confounding factors in a Confounding factors in a diabetic for emergency diabetic for emergency

surgerysurgery Usually associated withUsually associated with

infectious processinfectious process pronounced hyperglycemia, pronounced hyperglycemia,

dehydration and hypovolemiadehydration and hypovolemia metabolic decompensationmetabolic decompensation ± DKA± DKA

Start aggressive treatment of DKAStart aggressive treatment of DKA complete resolution is usually not possible without complete resolution is usually not possible without

correction of the surgical problemcorrection of the surgical problem volume resuscitation (remember losses due to volume resuscitation (remember losses due to

precipitating cause)precipitating cause) partial correction of hyperglycemia, metabolic partial correction of hyperglycemia, metabolic

acidosis and ketosis acidosis and ketosis Consider bicarbonate if pH<6.9/7.0; bicarb conc. < Consider bicarbonate if pH<6.9/7.0; bicarb conc. <

10 mEq/L; hypotension unresponsive to IV fluids)10 mEq/L; hypotension unresponsive to IV fluids) insulin insulin bolusbolus & infusion as in the non surgical & infusion as in the non surgical

patient in DKApatient in DKA re-established urine output re-established urine output potassium supplementationpotassium supplementation phosphate supplementationphosphate supplementation start treatment of infectious process, if presentstart treatment of infectious process, if present

Aim: Aim: definite trend towards metabolic definite trend towards metabolic improvementimprovement

Monitor more oftenMonitor more often

Till thenTill then

Intra-op management?Intra-op management?

Post-op management?Post-op management?

What do persistent ketosis What do persistent ketosis with S. bicarb < 20 mEq/L & with S. bicarb < 20 mEq/L &

normal BG indicate?normal BG indicate?

Continue management of DKAContinue management of DKA

Monitor more oftenMonitor more often

There will usually be a rapid decrease There will usually be a rapid decrease in insulin requirements after surgery in insulin requirements after surgery

metabolic control regainedmetabolic control regained need for careful and frequent monitoring need for careful and frequent monitoring

of BS and metabolic parametersof BS and metabolic parameters Persistent ketosis with S. bicarb < 20 Persistent ketosis with S. bicarb < 20

mEq/L & normal BG indicate need for mEq/L & normal BG indicate need for intracellular glucose and insulin for intracellular glucose and insulin for reversal of lipolysisreversal of lipolysis

Most of the poorly controlled Most of the poorly controlled diabetics can be controlled in about diabetics can be controlled in about 12 h 12 h Start insulin infusionStart insulin infusion

Check blood gases and capillary glucose Check blood gases and capillary glucose hourlyhourly

Give sufficient glucose and potassium Give sufficient glucose and potassium

DM with uncontrolled BS DM with uncontrolled BS for semi-em tomorrowfor semi-em tomorrow

Diabetic ketoacidosis (DKA)Diabetic ketoacidosis (DKA) vs. vs. Hyperglycemic, hyperosmolar Hyperglycemic, hyperosmolar

nonketotic state (HHNS)nonketotic state (HHNS)

Diagnosis of DKA: pHa < 7.3, HCO3 < 15 mmol.l-

1, BG > 250 mg.dl-1 Moderate

ketonemia and ketonuria

HHNS: pHa > 7.3 HCO3 > 20mmol.l-1

BG > 28mmol.l-1 (500 mg.dl-1)

Absent/minimal serum ketones

Urinary ketones -/minimal

Osmolality > 330 mOsm.kg-1

Case 3Case 3

25 year, pregnant lady, diagnosed as 25 year, pregnant lady, diagnosed as diabeticdiabetic

What is Gestational DM?Time of occurrence?

Relevance?

Glucose intolerance which has its Glucose intolerance which has its onset in, or is first diagnosed during, onset in, or is first diagnosed during, pregnancy pregnancy

Typically occurs in latter halfTypically occurs in latter half

Thus AFTER organogenesis and thus Thus AFTER organogenesis and thus not a cause for congenital anomaliesnot a cause for congenital anomalies

Relevance of pre-existing diabetes in Relevance of pre-existing diabetes in pregnancy?pregnancy?

Organogenesis might get affected if not Organogenesis might get affected if not handled BEFORE conceptionhandled BEFORE conception

End-organs may be involvedEnd-organs may be involved Watch out for autonomic neuropathyWatch out for autonomic neuropathy

Incidence of acid aspiration may be moreIncidence of acid aspiration may be more

Airway management may be more Airway management may be more difficultdifficult

Glycolation of Hb decreases RBC OGlycolation of Hb decreases RBC O2 2

transport in pregnant patientstransport in pregnant patients

Important considerations if pregnant Important considerations if pregnant diabetic undergoes LSCS?diabetic undergoes LSCS?

Any special precautions in the neonate?Any special precautions in the neonate?

The mean umbilical cord venous blood The mean umbilical cord venous blood glucose and insulin levels are higher glucose and insulin levels are higher and glucagon levels lower in mothers and glucagon levels lower in mothers with poor BS controlwith poor BS control

Increased insulin levels lead to neonatal Increased insulin levels lead to neonatal hypoglycemia and delayed release of hypoglycemia and delayed release of glucagonsglucagons

Monitor BS level of neonate Monitor BS level of neonate

There is also evidence that hypotension There is also evidence that hypotension following regional anesthesia in the following regional anesthesia in the presence of hyperglycemia might presence of hyperglycemia might produce maternal lactic acidosis and produce maternal lactic acidosis and consequent fetal acidosisconsequent fetal acidosis

Insulin requirements may fall Insulin requirements may fall remarkably after delivery and thus remarkably after delivery and thus constant monitoring in HDU is vital in constant monitoring in HDU is vital in the post-operative periodthe post-operative period

Important considerations if pregnant Important considerations if pregnant diabetic undergoes some surgery other diabetic undergoes some surgery other than LSCS?than LSCS?

There is evidence that tight control of There is evidence that tight control of BG might be of benefit for the BG might be of benefit for the pregnantpregnant diabetic (and her future diabetic (and her future offspring)offspring)

Thus strive hard for tight control as Thus strive hard for tight control as the pregnancy is to continue after the pregnancy is to continue after anesthesia and surgeryanesthesia and surgery

Department of Anesthesiology, Intensive Care & Perioperative Medicine

MAMC & Associated Lok Nayak Hospital

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diabetes presentation rakesh kumar

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