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การให้ยาระงับความรู้สึก ในผู้ป่วยโรคเบาหวาน และโรคต่อมไทรอยด์ พญ. รัตนาภรณ์ บุริมสิทธิชัย ภาควิชาวิสัญญีวิทยา โรงพยาบาลจุฬาลงกรณ์

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Presentation on theme: "การให้ยาระงับความรู้สึก ในผู้ป่วยโรคเบาหวาน และโรคต่อมไทรอยด์ พญ. รัตนาภรณ์ บุริมสิทธิชัย ภาควิชาวิสัญญีวิทยา โรงพยาบาลจุฬาลงกรณ์"— Presentation transcript:

1 การให้ยาระงับความรู้สึก ในผู้ป่วยโรคเบาหวาน และโรคต่อมไทรอยด์ พญ. รัตนาภรณ์ บุริมสิทธิชัย ภาควิชาวิสัญญีวิทยา โรงพยาบาลจุฬาลงกรณ์

2 การให้ยาระงับ ความรู้สึกในผู้ป่วย โรคเบาหวาน

3 Criteria for the diagnosis of DM 1.FPG ≥126 mg/dl (NPO at least 8 h) or 2.Symptoms of hyperglycemia (polyuria, polydipsia and unexplained weight loss) and a casual plasma glucose ≥200 mg/dl (any time) or 3.2-h plasma glucose ≥200 mg/dl during an OGTT Repeat testing on a different day

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5 Impaired fasting glucose (IFG) Impaired glucose tolerance (IGT) Fasting plasma glucose levels ≥100 mg/dl but <126mg/dl or 2-h values in the OGTT of ≥140 mg/dl but <200 mg/dl Pre-diabetes Associate with the metabolic syndrome : obesity, dyslipidemia and hypertension

6 Metabolic abnormality Hyperglycemia –Osmotic diuresis, dehydration, electrolyte imbalance Lipolysis –Increased serum free fatty acid, ketone Increased low density lipoproteins Protein breakdown Stress –cortisol, glucagon, catecholamine, growth hormone

7 Classification of DM Type 1 –Destruction of pancreatic β cells (autoimmune) –Absolute insulin deficiency and requirement Type 2 –Variable degrees of insulin deficiency and resistance –Diet control, oral hypoglycemic drugs, insulin Other –Steroid Gestational diabetes

8 Common insulin preparations OnsetPeakDuration Short acting -Regular -Lispro/Aspart 30-60min 5-15min 2-3h 30-90min 8-10h 4-6h Intermediate acting -NPH/Lente -Glargine 2-4h 4-10h none 12-20h 20-24h Long acting -Ultralente6-10h10-16h24-48h Premixed -Humulin70/ min2-12h18-24h

9 Common preparations of oral hypoglycemic drugs DrugsDuration (h) Adverse effects Sulfonylureas First generation Chlorpropamide (Diabenese) Second generation Glyburide (Glibenclamide, Daonil, Euglucon) Glipizide (Minidiab) hypoglycemia cholestatic jaundice agranulocytosis Biguanide Metformin (Glucophage)7-12 lactic acidosis (elderly, renal insufficiency) Thiazolidinediones Rosiglitazone (Avandia) Pioglitazone (Actos) 24 increased cholesterol level Alpha-glucosidase inhibitor Acarbose4dyspepsia

10 Complications of DM Acute complications –Hypoglycemia –Diabetic ketoacidosis (DKA) –Hyperosmolar nonketotic coma Chronic complications –Macrovascular : atherosclerosis –Microvascular : diabetic retinopathy, nephropathy, neuropathy

11 Hypoglycemia –Glucose level < 50 mg/dl –Fasting, long-acting insulin/OHD, renal insufficiency –Altered mental status, coma and seizure –Physiologic responses to catecholamines –Diabetic patient may be symptomatic at higher glucose level –Anesthetized patient, beta blocker –50 ml of 50% glucose IV

12 Diabetic ketoacidosis (DKA) –Type 1 DM –Metabolism of free fatty acid –Glucose mg/dl, increased anion gap metabolic acidosis –Dehydration, osmotic diuresis, Kussmaul breathing, fruity breath, nausea and vomiting, abdominal pain, ileus, leukocytosis and elevated amylase level –Precipitating factors : infection, surgical stress, trauma, lack of insulin therapy

13 Management of diabetic ketoacidosis –Identify and treat precipitating causes –RI 10 unit IV bolus followed by an infusion at blood glucose/150 unit/hr –NSS infusion : vital signs and urine output –Potassium replacement when urine output > 0.5 ml/kg/hr –Add 5%dextrose infusion when glucose decreased to 250 mg/dl –Serial glucose and electrolyte level –Hemodynamic monitoring

14 Hyperosmolar nonketotic coma –Type 2 DM under stress –Glucose level > 600 mg/dl –Profound dehydration, confusion, coma and seizures –Intravascular thrombosis –Volume resuscitation : NSS –Rapid correction of hyperosmolarity leading to cerebral edema

15 Preoperative evaluation Preoperative glucose level control –Fasting blood glucose –HbA1c < 7 mg/dl End organ dysfunction –Atherosclerosis Coronary artery disease : myocardial ischemia/infarction Cardiomyopathy Peripheral vascular disease Cerebrovascular disease

16 End organ dysfunction –Diabetes nephropathy 40-50% of DM patients Albuminuria ACEIs, ARB –Diabetic retinopathy –Diabetic stiff joint syndrome 40% in DM type1 Difficult laryngoscopy : decrease mobility of atlanto-occipital and tempero-mandibular joint Prayer sign –Peripheral neuropathy : pressure injury

17 End organ dysfunction –Diabetic autonomic neuropathy ANS reflex dysfunction Old age, DM > 10 year, CAD and beta-blocker Limited compensation for intravascular volume changes Predispose to cardiovascular instability –Exaggerated pressor response to tracheal intubation –Postinduction hypotension –Sudden cardiac death Intraoperative hypothermia

18 Clinical signs of diabetic autonomic neuropathy Hypertension Silent myocardial ischemia/infarction Orthostatic hypotension Lack of HR variability Reduced HR response to atropine and propranolol Resting tachycardia Gastroparesis Neurogenic bladder Lack of sweating Impotence

19 Anesthetic management Avoid hypoglycemia Signs and symptoms of hypoglycemia will be masked by GA, beta-blocker –RA and peripheral nerve block Monitoring –Blood glucose –Invasive monitoring NPH vs protamine sulfate Severe bradycardia : epinephrine

20 Perioperative glycemic control Anesthetic agents : modulation of SNS Association between hyperglycemia and increased morbidity and mortality Type, severity of DM and extent of surgery –Hold short acting agents on the day of surgery, long acting agents 2-3 days prior –Cardiopulmonary bypass, pregnancy, neurological surgery Goal mg/dl

21 Perioperative insulin regimen Bolus administration –½ of the usual intermediate-acting insulin subcutaneously on the morning –Regular insulin 1 unit reduce blood glucose 30 mg/dl Insulin infusion –Separate IV line –Regular insulin 10 unit in NSS 100 ml (1u/h=10ml/h) –Blood glucose/150 = insulin unit/h 5%dextrose infusion ml/h Serial blood glucose every 1-2 h

22 Postoperative management Continue glucose level control –Osmotic diuresis –Infection –Poor wound healing Lactate-containing fluid –Rising in blood glucose level hr postoperatively

23 การให้ยาระงับ ความรู้สึกในผู้ป่วยโรค ต่อมไทรอยด์

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25 Thyroid function test Total serum triiodothyronine (T3) and thyroxine (T4) Free T3 and T4 Thyroid hormone binding rate (THBR) Thyroid stimulating hormone (TSH) Normal plasma T mcg/dl Normal plasma T ng/dl Normal THBR 30-40% Normal TSH 8 µIU/ml

26 Test of thyroid gland function T4T3TSHTHBR Hyperthyroidism Primary hypothyroidism Secondary hypothyroidism Pregnancy

27 Hyperthyroidism

28 Grave’s disease Thyroid adenoma Toxic multinodular goiter Thyroiditis Pituitary tumor Iatrogenic Exogenous iodide

29 Manifestations of hyperthyroidism Weight loss, diarrhea, skeletal muscle weakness, hyperactive reflexes, warm and moist skin, heat intolerance, diaphoresis, nervousness Tachycardia, high CO, elevated SBP, decrease DBP, heart failure, atrial fibrillation Aggravate myocardial ischemia Increased beta receptor sensitivity

30 Manifestations of hyperthyroidism Mild anemia, thrombocytopenia Fine tremor, exophthalmos, goiter Bone resorption and hypercalcemia

31 Hyperthyroidism Treatment –Medical treatment Antithyroid drugs : propylthiouracil, methimazole Beta adrenergic blocking agent Inorganic iodide Corticosteroid –Radioactive iodine –Surgical treatment Failed medical therapy, cancer, symptomatic goiter, cosmetic

32 Mechanism of action of antithyroid drugs MechanismPTUMMILiCO3SSKIβ blockersteroid Block Iodine uptake Block T4 synthesis Block T4 release Block peripheral conversion T4 to T

33 Preoperative evaluation Euthyroid state before surgery –antithyroid drugs 6-8 wk Controlled hyperdynamic CVS –resting heart rate < 90 bpm Inorganic iodide : reduce size Continue medications Side effects of antithyroid drugs –Rash, fever, nausea, agranulocytosis, hepatitis, arthralgia, hypothyroidism

34 Preoperative evaluation Emergency surgery –Esmolol mcg/kg/min –Dexamethasone 8-12 mg/d Airway obstruction –Substernal goiter –X-ray neck –CT Premedication –Benzodiazepine –Anticholinergic

35 Tracheal comprssion

36 Tracheal compression

37 Anesthetic management Regional anesthesia General anesthesia Adequate depth of anesthesia Reinforced ETT Avoid meds that stimulate SNS –Ketamine, pacuronium, indirect-acting vasopressor Thiopental : antithyroid activity

38 Anesthetic management Chronic hypovolemia and vasodilation –Exaggerated hypotension postinduction Unchanged MAC Eyes protection Maintain body temperature Myasthenia gravis

39 Thyrotoxic crisis (Thyroid storm) Undiagnosed/uncontrolled hyperthyroid with surgical stress or illness 6-18 hr postoperative Tachycardia, dysrhythmia, CHF, MI, dehydration, shock, hyperthermia, agitation Differential diagnosis –Pheochromocytoma –Malignant hyperthemia –Neuroleptic malignant syndrome –Light anesthesia

40 Treatment of thyrotoxic crisis Precipitating causes Cooled crystalloid solution Sodium iodide 250 mg PO or IV q 6 h PTU mg PO or NGT q 6 h Hydrocortisone mg IV q 6 h Propranolol mg PO q 4-6 h or 1-2 mg IV or esmolol infusion mcg/kg/min Cooling blanket, acetaminophen and meperidine mg IV q 4-6 h to prevent shivering Digoxin if AF with RVR

41 Post-thyroidectomy complication Recurrent laryngeal nerve injury –Unilateral –bilateral Tracheal compression –Hematoma –Tracheomalacia Hypoparathyroidism –Hypocalcemia h postoperatively –Inspiratory stridor, laryngospasm

42 Hypothyroidism

43 Etiology –Primary hypothyroidism Thyroid gland dysfunction : Hashimoto’s thyroiditis, previous subtotal thyroidectomy, RIA, irradiation of the neck Thyroid hormone deficiency : antithyroid drugs, dietary iodine deficiency –Secondary hypothyroidism Hypothalamic dysfunction Anterior pituitary dysfunction

44 Clinical manifestations Reduction in metabolic activity –Weight gain, lethargy, slow mental functioning, cold intolerance, slow movement Cardiovascular –Bradycardia, decreased contractility, CO –Increased SVR, diastolic hypertension –Pericardial fluid –Angina pectoris, CHF

45 Clinical manifestations Respiratory –Depressed ventilatory responsiveness to hypoxia and hypercarbia, pleural effusion –Sleep apnea Renal –Decreased renal blood flow, hyponatremia Anemia, coagulopathy Delayed gastric emptying, constipation

46 Clinical manifestations Hypothermia Cool, dry and mottled extremities Blunted stress response and adrenal depression Dull facial expression, depression

47 Myxedema coma Stupor or coma, hypoventilation, hypothermia, hypotension, hyponatremia Mortality 25-50% Infection, surgery, trauma Life-threatening surgery IV thyroid hormone –Precipitate myocardial ischemia Acute primary adrenal insufficiency –Stress dose hydrocortisone

48 Management of myxedema Tracheal intubation & controlled ventilation Levothyroxine mcg IV over 5-10 min then 100 mcg IV q 24 h Hydrocortisone 100 mg IV then 25 mg IV q 6 h Fluid and electrolyte therapy Warming blanket

49 Preoperative evaluation Postpone elective surgery in severe hypothyroidism (T4 < 1 mcg/dl) Mild/moderate hypothyroidism Preoperative thyroid hormone replacement vs ischemic heart disease Difficult intubation : large tongue Premedication –Sedative, thyroid hormone, steroid

50 Anesthetic considerations Increased sensitivity to depressant drugs Slow drug metabolism Decreased cardiac output, cardiac contractility Bradycardia, unresponsive baroreceptor reflexes Decreased catecholamine response Impaired ventilatory responses to arterial hypoxemia or hypercarbia Hypovolemia Hyponatremia Hypoglycemia Hypothermia Delayed gastric emptying Adrenal insufficiency

51 Anesthetic management Regional anesthesia –Decrease dose, prone to toxicity General anesthesia –Susceptible to hypotensive effect of anesthetics –Ketamine –Thiopental –Short-acting drugs Maintain normothermia

52 Postoperative care Delayed awakening Hypoventilation Hypothermia

53 Thank you for your attention


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