stress response to surgery under general anesthesia in type 2 diabetic patient dr kawsar sardar, md...
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Stress Response to Surgery Under General Anesthesia in
Type 2 Diabetic Patient
Dr Kawsar Sardar, MD
Associate professor Department of Anesthesiology, BIRDEM, Bangladesh
Joint secretary, Bangladesh Society of Anesthesiologists
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BANGLADESH
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• Central Location• 700-bed multidisciplinary hospital • Very large OPD (4500 patients /day)• 60-70 diabetic patients under went operative
procedure everyday• WHO Collaborating Centre for Research on
Diabetes and its complications (Till 2014)
Bangladesh Institute of Research & Rehabilitation in Diabetes, Endocrine and Metabolic Disorders (BIRDEM)
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– One of Largest diabetes care provider in the world
– One of Largest non-profit health care network outside Govt. in the world
– Provide healthcare through a network of hospitals & educational institutions of its own
Uniqueness of BADAS
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Our network all over the country
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Diabetes Mellitus
• One of the major chronic diseases
affecting mankind all over the world
• It has been declared as an epidemic
in developing countries by both the
World Health Organization and
International Diabetes Federation
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Diabetes – Global Epidemic
HIGHEST ABSOLUTE NUMBERS
CHINA 90 million ●
INDIA 61 million ●
HIGHEST PREVALENCES RATE
● MIDDLE EAST 1 in 5 adultsHIGHEST REGIONAL INCREASEBETWEEN 2011 - 2030
● AFRICA – 90% increase
Killer Facts:• More than 382 million
(8.3%) people live with diabetes – by 2035 will be 592 (9.9%) million
• 80% live in low- and middle-income countries (LMCs)
• 4.6 million deaths each year
• Every 8 seconds, someone in the world dies from diabetes
Diabetes Atlas
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Diabetes in Bangladesh
• The estimated prevalence of diabetes
in Bangladesh is around 6.8%
• Mostly Type 2 diabetes (99%)
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Fifty percent of all diabetic patients
present for surgery during their life
time
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Inevitably, diabetic patients presenting for incidental surgery, or surgery related to their disease, will place an increasing burden on
anesthetic services
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Perioperative morbidity and mortality are greater in diabetic than in nondiabetic patients
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In response to stress during surgery and anesthesia- the biochemical parameters like
stress hormone being altered
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The neuroendocrine system comes into play to maintain fuel requirements by glycogenolysis
and gluconeogenesis through stress hormones catecholamines, glucagon, cortisol, and growth
hormone
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The endocrine hormones like cortisol, thyroxin, glucagon, and growth hormone are released
due to surgical stress under hypothalamopituitary control
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Surgery elicits a stress response that is directly proportional to the degree of tissue trauma
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Why Stress response to surgery under anesthesia is complicated in diabetic patients?
• Insulin deficiency • Counter regulatory hormones activity• Autonomic neuropathy• Electrolytes transport• Preoperative fasting states• Dehydration
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These lead to abnormal metabolism of carbohydrate, protein and fat as well as electrolyte imbalance
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Anesthesia also principally affects glucose metabolism through the modulation of sympathetic tone
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Our study
• It was designed to explore the metabolic and stress response to lower abdominal surgery under general anesthesia in type 2 diabetic subjects with particular focus on
– Serum glucose– C-peptide– Cortisol – Electrolytes
• It also investigated the stress response in different treatment variability
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OBJECTIVES
• To investigate the glycemic response to surgery in type 2 diabetic subjects under general anesthesia.
• To investigate the serum cortisol response to surgery in type 2 diabetic subjects under general anesthesia.
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OBJECTIVES
• To investigate the stress response in insulin and combined insulin-OHA treated type 2 diabetic subjects during surgery under general anesthesia.
• To investigate the stress response in hypertensive and normotensive type 2 diabetic subjects during surgery under general anesthesia.
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Study design
The study was a cross sectional prospective study
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Study subjects
100 subjects who were admitted in BIRDEM hospital in fit physical condition (ASA Class II) were received total abdominal hysterectomy under general anesthesia
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Exclusion criteria
• Influencing variable like patients taking steroid or analgesics
• Pre operative plasma glucose <5 mmol/l and >10 mmol /l
• Patients of ASA Class III, IV, V and E• Obese and malnourish
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Design of general anesthesia
• Induction: Thiopental, fentanyl, vecuronium• Maintenance: Halothane, nitrous oxide with
oxygen
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Sample collection
Three samples (8-10 ml) were collected– The first sample- just before anesthesia – 2nd sample- 10 minutes after incision– 3rd sample- 10 minutes after extubation
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Control
First sample of each subject were served as a control
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ANALYTICAL METHODS
• Plasma glucose was measured by glucose oxidase method (Randox, UK).
• Serum electrolytes were measured by Dry Chemistry method (DT-60, USA).
• Serum C-peptide was measured by chemiluminescent immunoassay (Immulite, USA).
• Serum cortisol was measured by chemiluminescent immunoassay (Immulite, USA).
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STATISTICAL ANALYSIS
Statistical analysis was performed using SPSS (Statistical Package for Social Science) software for Windows version 17 (SPSS Inc., Chicago, Illinois, USA).
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RESULTS AND OBSERVATIONS
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PTo PT1 PT20
2
4
6
8
10
12
Plasma Glucose (mmol/l)
PTo PT1 PT21.9
1.95
2
2.05
2.1
2.15
2.2
C-peptide (ng/ml)
Figure: Perioperative glycemic and insulinemic status of the study subjects
*
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PTo PT1 PT20
5
10
15
20
25
30
35
Cortisol (ng/ml)
Figure: Perioperative serum cortisol status of the study subjects
*
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PTo PT1 PT2135.4135.6135.8
136136.2136.4136.6136.8
137137.2
S Sodium (mmol/l)
PTo PT1 PT22
2.5
3
3.5
4
S Potassium (mmol/l)
Figure: Perioperative serum electrolytes level of the study subjects
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Seru
m G
lucose
(mm
ol/
L)
C-P
ep
tid
e
(ng
/ml)
Figure: Perioperative glycemic and insulinemic status of insulin and insulin-OHA treated subjects
**
*
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Figure: Perioperative serum cortisol status of insulin and insulin-OHA treated subjects
Seru
m C
ort
isol
(ng
/ml)
**
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Seru
m N
a+
(mm
ol/
l)
Seru
m K
+
(mm
ol/
l)Figure: Perioperative serum electrolytes status of insulin and insulin-OHA treated subjects
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Seru
m G
lucose
(mm
ol/
l)
Seru
m C
-Pep
tid
e (
ng
/ml)
Figure: Perioperative glycemic and insulinemic status of hypertensive and normotensive study subjects
**
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Seru
m C
ort
isol
(ng
/ml)
Figure: Perioperative serum cortisol status of hypertensive and normotensive study subjects
*
*
*
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Figure: Perioperative serum electrolytes status of hypertensive and normotensive study subjects
Seru
m N
a+ (
mm
ol/
l)
Seru
m K
+ (
mm
ol/
l)
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The data lead to following conclusions
1. Lower abdominal surgery under general anesthesia in well controlled type 2 diabetic subjects is accompanied by a hyperglycemic response which results from rise of insulin antagonists like cortisol rather than fall of insulin secretion.
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The data lead to following conclusions
2. Insulin treatment alone is more effective than insulin-OHA combination to control blood glucose in type 2 diabetic subjects undergoing surgery under general anesthesia; but the two treatment modalities lead to similar cortisol response.
3. Coexisting hypertension is associated with insulin hyposecretion leading to hyperglycemia in type 2 diabetic patients undergoing surgery under general anesthesia.
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RECOMMENDATIONS
1. Insulin rather than insulin-OHA may be a good choice of treatment for preoperative glycemic control.
2. Special attention should be given regarding perioperative glycemic control in type 2 diabetic coexisting hypertensive patients.
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RECOMMENDATIONS
3. Other stress hormones like glucagon, catecholamines, growth hormone and heat shock proteins may be measured for better quantification of the surgical stress.
4.To reduce the stress response- premedication and other anesthetic drugs, by increasing the dose of same anesthetic agents or anesthetic procedure may be applied for better management of type 2 diabetic subjects.
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TH A N K Y O U