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PRE ANESTHETICPRE ANESTHETIC
EVALUATIONEVALUATION
FOR
DIABETES MELLITUSLIYA ABRAHAM
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INTRODUCTIONINTRODUCTION Diabetics come for surgeries for common
problems and also for procedures prompted by
long term complications They face several challenges due to imbalance
between insulin and its counter regulatory
hormones secreted during stress
Hypo tension , hypovolemia , acidosis, in post op
period face poor wound healing , ARF and
infection
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PREANESTHETIC EVALUATIONPREANESTHETIC EVALUATION
HISTORY:
History specific to diabetes: polyuria,polydipsia, weight loss weakness
Known diabetic duration since onset
H/o infections skin boils carbuncle, fevercandidiasis , burning micturition,non-healing foot ulcers etc.
H/s/o episodes of unconsciousness
H/o events precipitating DKA likeinadequate insulin ,infection- UTI, RTI ,GE,SEPSIS
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History of chronicHistory of chronic
complicationscomplications
Diabetic retinopathy: h/o diminution or loss
of vision Diabetic neuropathy: Mononeuropathy- 3rd
6th or 7th nerve involvement
Peripheral neuropathy- sensory loss gloveand stocking type
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History of autonomic neuropathyHistory of autonomic neuropathy
dizziness, lightheadedness, diminution of vision
on standing , syncope and heat intolerance
Gastro paresis: anorexia, nausea, vomiting early
satiety or abdominal bloating Genitourinary dysfunction: cystopathy which
includes hesitancy decreased voiding frequency
incontinence and recurrent UTI,
Erectile dysfunction, retrograde ejaculation or
female sexual dysfunction
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History contd..History contd.. Drug history: OHA name ,dosage and timing of
ingestion Insulin type dosage and timing details
Details of all other co morbidities IHD,HTN,CRFand medications
Past history: hospitalizations in past anycomplications and details
Family history : of diabetes
Personal history regarding dietary intake if high
calorie diet - may be on higher dose medication andec dose required pos op during fasting also askfor the extent of daily physical activity as inc doserequirement when phy activity limited
perioperatively
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Clinical examinationClinical examination General- nourishment and built
Vitals : Pulse resting tachycardia
_ irregularity
_ changes with deep breathing,
valsalva and sustained hand grip
Blood pressure- look for orthostatic hypotension
Urine output
Temperature increased in infections
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Systemic examinationSystemic examination RS : AIRWAY:
specifically look for stiff jointsprayer sign/ palm print sign
IP joint stiffness $ cervical joint
stiffness
Look specifically for any signs of resp tractinfections
CNS: - detailed examn including
- cranial nerves for mononeuropathy- sensory loss
-muscle wasting
- sup and deep tendon reflexes
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InvestigationsInvestigations
Urine routine: glucose, albumin, ketonebodies, microscopy
Blood glucose levels: FBS, PPBS, HbA1c
Renal function: BUN, serum creatinine,serum electrolytes
CVS ECG, lower threshold for stresstesting and ECHO
Tests for autonomic neuropathy- Breathing tests ,Tilt-table test , Quantitative sudomotor axonreflex test (QSART ), Thermoregulatory sweat
test, Ultrasound.
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Pre operative instructionsPre operative instructions NPO for 8 hrs . They should preferably be 1st on
the list to prevent prolonged fasting an
hypoglycemia an if prolonged blood glucose hasto be monitored
Ranitidine and metoclopramide are given night
before an day of surgery to dec acid secretion and
promote gastric emptying
FBS, SE and UKB on the morning of surgery
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Adjustment of diabetes medicationAdjustment of diabetes medication
Type 2 diabetes on diet control for short electiveprocedures no treatment only blood glucose
monitoring
Patients on OHA s like newer generation
sulfonylureas(ex.glyburide, glipizide) andthiazolidinediones(ex. Rosiglitazone, pioglitazone)
OHA withheld on the morning of surgery
Metformin should be stopped 24 hrs before the
procedure to prevent the possibility of lactic
acidosis if the patients renal function gets
compromised
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Adjustment of diabetes medicationAdjustment of diabetes medication
Patients on insulin- minor procedure skip the
morning dose of insulin
Patients undergoing major surgeries with longer
recovery periods on either OHA s or on long
acting insulin should be discontinued and started
on a regimen of short acting insulin
All type 2 diabetics uncontrolled or undergoingmajor surgeries are managed like insulin
dependent diabetics
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Insulin therapyInsulin therapy
Non tight regimen At 6am on the day of surgery start 5% D
maintenance rate and the morning dose
of insulin is given subcutaneously
Tight control regimen
Regimen 1:
5%D started @ 50 cc/hr piggyback insulin infusion (50u in 250ml
NS) insulin rate(u/hr) = plasma
glucose(mg/dl)/150
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Insulin therapyInsulin therapy
GIK regimen- Alberti and Thomas Initial 500ml 10% D +10mmol Kcl+15U
insulin @ 100ml/hr
Glucose 11.1soln with 20u @4 u /hr
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Emergency proceduresEmergency procedures
Type 1 pt with ketoacidosis or type 2 pt withhyperosmolar coma requires stabilization beforesurgery unless an acute emergency
Dehydration electrolyte imbalances have to beadequately corrected
Ketoacidosis should b allowed to resolve and ptshould be stabilized on GIK regimen if surgery isnot life saving
In case of pressing surgical conditions likevascular injury or intra abdominal emergency , therisks of delay must be weighed against incompletemetabolic resolution and the surgical stress indeciding the optimum time for surgery.
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