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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