Modrator : Dr. Maya Presented by : Bikash ranjan ray Case presentation Diabetes Mellitus Modrator : Dr. Maya Presented by : Bikash ranjan ray www.anaesthesia.co.in anaesthesia.co.in@gmail.com

HISTORY Gajender kumar 55 yr , male Bulandahar, UP Presenting complaint: Nonhealing ulcer bilateral foot - 2 month Pus discharge from left foot ulcer – 2 month Blackish discolouration of left foot - 10 days

History of present illness : Apparently alright 2 month back h/o injury to b/l foot – 2 month back Developed ulcer at trauma site No associated pain at the site of ulcer Purulent discharge from left foot ulcer : treated with antibiotics and dressing Blackish discoloration of left foot – 10 days No h/o change in colour with change in temprature No H/o fever, swelling of lower limb

Past history : K/c/o DM – 6 yr Previously was on OHA for 4yrs Changed to insulin since last 2 yrs H/o poor compliance to treatment and poor control of blood sugars Presently on insulin Human actrapid 12 IU BBF,BL & BD Insulatard 25 IU after dinner On this regimen blood sugars were controlled H/o similar discoloration in Lt toe 1yr back, amputation done ↓ RA, U/E

H/o syptoms suggestive of hypoglycemic episodes H/o tingling and numbness in both lower limbs since 2 yrs No history s/o any other medical illness ( HTN , TB , CAD, Asthma ,etc )

No h/o decreased vision Chest pain, palpitations, breathlessness, orthopnea/ PND, edema feet, syncope, cough ↓ urine output, generalized edema Giddiness on change of posture No h/o decreased vision Limited mobility since last 1 month due to b/l foot ulcer Initially could climb 3 flights of stairs No history of any drug allergy

Treatment history: Inj. Levoflox 500 mg i.v. od Inj. Metrogyl 500mg 8th hrly Personal history : Bowel and bladder habits: normal Alcohol intake : occasional Cigarette smoker: smoked for 15 yrs, 4-5/day, stopped since last 3yrs Family history : Insignificant

General Examination Awake ,Conscious, Oriented, sitting comfortably in bed Wt: 55 kg, ht: 164 cm Afebrile No pallor, icterus, cyanosis, clubbing, jaundice, lymphadenopathy JVP: not raised Good i.v. access

Pulse: 80/min, regular, adequate volume, no radioradial or radiofemoral delay BP in right arm: 138/ 84 mm of Hg supine position, 130/ 80 mm of Hg sitting position RR: 20/ min, regular HR response to deep breathing: > 15bpm

Local examination Left foot: heel ulcer 8x12 cm, blackish discoloration till ankle, no line of demarcation, purulent discharge, foul smelling Surrounding skin: swollen, erythematous, tender Right foot: 2×4 cm ulcer , no discharge

Systemic Examination: CVS: Apex beat in 5th intercoastal space, midclavicular line S1, S2 normal No murmurs Respiratory system: B/L air entry present No crepitations or rhonchi Abdomen: soft, no organomegaly Spine: normal

CNS: Higher functions normal Cranial nerves : normal Sensory examination: B/L lower limb Pain, touch and temperature sensation were decreased in the distal parts Pressure , position sense and vibration sense intact & normal in both the limbs Motor examination: Power and tone: normal in both the limbs Reflexes: Ankle jerk: B/L absent all other reflex present

Airway examination Mouth opening: 5 cm MMP class: 2 Neck movements: WNL TMD: 6 cm Teeth: intact Prayers sign: negative

Provisional Diagnosis DM with b/l foot ulcer ,with gangrene of left lower limb Surgical plan : Below knee amputation of left leg

Investigations: Hb = 10.0 g/dl TLC =14500 Platelet count =3,21,000 Na+/K+ =150/4.8 Urea = 58mg/d T. bil = 0.7 Pt = 12/ 13 CXR = WNL ECG= WNL Blood sugar : Fasting 156 mg/dl Urine sugar and ketones –ve

Anaesthesia

Diagnosis and Classification 1)Symptoms ( polyuria, polydipsia,wt loss )plus random plasma glucose >=200 mg/dl (11.1mmol/l) or 2) A fasting (>8hr)plasma glucose of >=126 mg/dl (7 mmol/l). 3)A glucose conc . Of >=200 mg/dl (11.1mmol/l)2 hrs after oral ingestion of 75 g glucose 2004 ADA , reduces normal fasting glucose thresold from 110mg/dl to 100 mg/dl (normal FBG = 70 – 100 ) Impaired fasting glucose = 101 – 125 mg/dl

Metabolic syndrome x At least 3 of the following: FPG ≥ 110 mg/dl Abdominal obesity (waist grith >40 in men and >35 in women ) Sr. triglycerides ≥ 150 mg/dl Sr. HDL <40 mg/dl in men and < 50 mg/dl in women Blood pressure ≥ 130/85 mmhg

Classification Class Pathogenesis Incidence Type 1 (Formerly juvenile or IDDM) Immune mediated idiopathic forms of β cell function absolute insulin deficiency 0.4% male =female usually young Type 2 (Formerly NIDDM) Insulin resistance relative insulin deficiency or secretory defect 6.6% adult onset Type 3 Specific types of DM genetic defect / disease of exocrine pancreas Type 4 Gestational DM 4% of pegnanrcies

Preoperative evaluation &risk assessment Classical diabetic complications Macroangiopathy - arteriosclerosis Microangiopathy - heart, kidney &retina Autonomic neuropathy - heart, GI &urinary tracts Peripheral neuropathy Collagen anomalies - respiratory tract & joints Unifying hypothesis - impaired glycosylation of proteins Systematic search of diabetic complications – key step

Perioperative complications with Hyperglycemia Dehydration, electrolyte & metabolic disturbances Predisposes to DKA Delayed wound healing Bacterial infection & postop wound infection Median glycemic threshold for neutrophil dysfunction 200 mg/dl Independent risk factor for increase in short & long term mortality after cardiovascular surgery Worsens clinical outcome in stroke, traumatic brain injury, global & focal cerebral ischaemia Haemorrhagic extension of ischaemic stroke

Benefits of normal blood glucose Maintenance of normal white blood cell & macrophage function Positive trophic & anabolic effects of insulin Improved erythropoiesis Decreased hemolysis Reduced cholestasis Less axonal dysfunction

Oral Hypoglycemic Agents Class Sulfonylurea Agents Duration Action Side-effects 1st generation Tolbutamide Chlorpropamide 6 -12 h 24 -72 h Up to 24h Increased pancreatic insulin release Receptor level action Hypoglycemia 2nd generation Glipizide Giburaide Glimepride

Class Agents Duration Action Side-effects Biguanides Metformin 7 -12 h Up to 24h Improve receptor sensitivity ? Reduction in resistance Pancreatic insulin release Lactic acidosis Liver dysfunction Glitizones Tro Rosi Pio Dar

Class Agents Duration Action Side-effects Glinides Repaglinide Nateglinide 3 h 4 h Rapid insulin secretion Reduced carbohydrate absorption Liver dysfn Diarrhea Abd pain Alpha –glucosidase inhibitor acarbose

Insulin preparations and guidelines

Traditional Regimens Χ “No glucose, no insulin” Limitations : Not suitable for insulin dependent diabetics Pt’s stores of glucose used to meet increased metabolic demands Patients taking long acting OHAs predisposed to hypoglycemia Acceptable for non-insulin dependent diabetics & minor surgical procedures Frequent blood sugar monitoring. May require insulin therapy

Non tight control” regimen Aim : Prevent hypoglycemia, ketoacidosis, hyperosmolar states Day before surgery : NPO > midnight Day of surgery : iv 5%D @1.5 ml/kg/hr (Preop + intraop) Subcut one half usual daily intermediate acting insulin on morning of surgery, increased by 0.5U for each unit of regular insulin dose of insulin subcut Postop : Monitor blood glu & treat on sliding scale Limitations: Insulin requirements vary in periop period Onset & peak effect may not correlate with glucose admn or start of surgery Hypoglycemia esp in afternoon Lowest therapeutic ratio

Tight control regimen I Aim : 79-120 mg/dl Protocol : Evening before, do pre-prandial bld glucose Begin iv 5%D @ 50 ml/hr/70 kg Piggyback to 5%D, infusion of regular insulin (50 U in 250 ml 0.9% NS) Insulin infusion rate (U/hr) = plasma glu (mg/dl) / 150 or /100 if on steroids or severe infection Repeat bld glu every 4 hours Day of surgery : Non dextrose containing solutions, Monitor blood glu at start & every 1-2 hours

Tight control regimen II Aim : Same as TC regimen I Protocol : Obtain a feedback mechanical pancreas & set controls for desired plasma glucose. Institute 2 iv drips for insulin & fluids

Alberti’s regimen 1979- Alberti & Thomas IV GIK solution [500ml 10% glucose + 10 units soluble insulin + 1 gm KCl @ 100 ml/hr] Before surgery - stabilize on soluble insulin regimen, omit morning dose of insulin Commence infusion early on morning & monitor glu at 2-3 hours < 90mg/dl or > 180 mg/dl replace bag with 5U or 15U respectively

Alberti’s regimen-Recent version Initial solution : 500ml 10% glu + 10 mmol KCl + 15 U Insulin, infuse at 100 ml/hr Check Blood glu every 2 hours Adjust in 5 U steps Discontinue if bld glu < 90 mg/dl Blood glu (mg/dl) Action <120 10 U insulin (2U/h) 120-200 15 U insulin (3U/h) >200 20 U insulin (4U/h)

Advantages : simple, Inherent safety factor, balance appropriate Criticism : hypoglycemia, water load & hyponatremia, cautious : poor renal function 20% or 50% D

Hirsh regimen Aim : Normoglycemia Infuse glucose 5 g/hr with pot 2-4 mmol/hr Start insulin infusion @.5-1U/hr Measure blood glucose hourly Blood glu (mg/dl) Action (insulin infusion) < 80 Turn off for 30 min, give 25 ml 50% D 80-120 ↓ by .3 U/h 120-180 No change in infusion rate 180-220 ↑ by .3 U/hr > 220 ↑ by 0.5 U/hr

Regular Insulin Sliding Scale RECOMMENDATIONS Supplement usual diabetes medications to treat uncontrolled high blood sugars Short term use (24-48 h) in a patient admitted with unknown insulin requirement Should not be used as a sole substitute, risk of DKA Periop changes in regional blood flow – unpredictable absorption

Split-mixed insulin regimen Combining multiple daily injections of intermediate or long acting insulin (NPH, lente, or ultralente) rapid or short acting insulins (Regular, insulin lispro, or insulin aspart) “1500 Rule” : (ICF) 1500/total insulin dose = how much 1 unit of regular insulin will decrease blood glucose.

Hypoglycemia BG < 50 mg/dl in adults and < 40 mg/dl in children whipple’s triad : low plasma glucose hypoglycemic symptoms resolution of symptoms with correction of blood sugar Sympathoadrenal : Weakness, sweating, ↑ HR, palpitations, tremor, nervousness, irritability, tingling, hunger Neuroglycopenia : Headache, ↓ temp, visual disturbances, mental confusion, amnesia, seizures, coma

Treatment : Discontinue insulin drip Give D 50 w iv patient conscious – 25 ml patient unconscious – 50 ml Recheck BG every 20 min & repeat 25 ml of D50 w if < 60 mg/dl Restart drip once BG is > 70 mg/dl

Diabetic autonomic neuropathy : Pupillary Decreased diameter of darkadapted pupil Argyll-Robertson type pupil Metabolic Hypoglycemia unawareness Hypoglycemia unresponsiveness Cardiovascular Tachycardia, exercise intolerance Cardiac denervation Orthostatic hypotension Heat intolerance Neurovascular Areas of symmetrical anhydrosis Gustatory sweating Hyperhidrosis Alterations in skin blood flow Gastrointestinal Constipation Gastroparesis diabeticorum Diarrhea and fecal incontinence Esophageal dysfunction Genitourinary Erectile dysfunction Retrograde ejaculation Cystopathy Neurogenic bladder Defective vaginal lubrication

Diagnostic tests for cardiovascular autonomic neuropathy : Resting heart rate > 100 beats/minute is abnormal Beat-to-beat heart rate variation The patient should abstain from drinking coffee overnight Test should not be performed after overnight hypoglycemic episodes When the patient lies supine and breathes 6 times per minute, a difference in heart rate of less than 10 beats/minute is abnormal An expiration:inspiration R-R ratio > 1.17 is abnormal Heart rate response to standing The R-R interval is measured at beats 15 and 30 after the patient stands A 30:15 ratio of less than 1.03 is abnormal Heart rate response to Valsalva maneuver The patient forcibly exhales into the mouthpiece of a manometer, exerting a pressure of 40 mm Hg, for 15 seconds A ratio of longest to shortest R-R interval of less than 1.2 is abnormal

Systolic blood pressure response to standing Systolic blood pressure is measured when the patient is lying down and 2 minutes after the patient stands A fall of more than 30 mm Hg is abnormal A fall of 10 to 29 mm Hg is borderline Diastolic blood pressure response to isometric exercise The patient squeezes a handgrip dynamometer to establish his or her maximum The patient then squeezes the grip at 30% maximum for 5 minutes A rise of less than 16 mm Hg in the contralateral arm is abnormal Electrocardiography A QTc of more than 440 ms is abnormal Depressed very-low frequency peak or low-frequency peak indicate sympathetic dysfunction Depressed high-frequency peak indicates parasympathetic dysfunction Lowered low-frequency/high-frequency ratio indicates sympathetic imbalance Neurovascular flow Noninvasive laser Doppler measures of peripheral sympathetic responses to nociception

X – ray cervical spine :

Prayer sign :

Finger print test :

Differential diagnosis of DKA :

Diagnostic criteria and deficits in DKA and HHS :

Pathogenesis of DKA and HHS :

Diabetes and anesthesia :

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