Diabetes Melitus

Morgans clinical anesthesiology, 4th edition Konsep Kunci : 1. Kemungkinan terjadi Diabetic autonomic neuropathy, membatasi kemampuan
kompensasi jantung pada perubahan volume intravaskular.

2. Pasien DM harus dievaluasi secara rutin mobilitas sendi temporomandibular dan

Vertebra cervicalis, untuk mengantisipasi kesulitan intubasi, yang terjadi pada 30% pasien DM tipe I Hiperglikemia kronik dapat menyebabkan glikosilasi protein jaringan dan membatasi pergerakan sendi. 3. Sulfonylureas and metformin sebaiknya dihentikan untuk 24-48 jam sebelum operasi karena masa kerja nya panjang. Metformin kembali diberikan bila fungsi ginjal dan hepar normal.

Perhatian anestesi pada pasien dengan DM Nilai Hba1c bisa membantu memprediksi pasien yang beresiko hiperglikemia perioperatif Pasien DM dengan HT, 50% beresiko terhadap diabetic autonomic neuropathy
Tanda klinis diabetic autonomic neuropathy Hypertension Painless myocardial ischemia Orthostatic hypotension Lack of heart rate variability1

Reduced heart rate response to atropine and propranolol Resting tachycardia Early satiety Neurogenic bladder Lack of sweating Impotence

Oxford

Preoperative Assessment

Cardiovascular: the diabetic is prone to hypertension, ischemic heart disease (may be silent), cerebrovascular disease, myocardial infarction, and cardiomyopathy. Autonomic neuropathy can lead to tachy- or bradycardia and postural hypotension. Renal: 40% of diabetics develop microalbuminuria, which is associated with hypertension, ischemic heart disease, and retinopathy. This may be reduced by treatment with ACE inhibitors. Respiratory: diabetics are prone to perioperative chest infections, especially if they are obese and smokers. Airway: thickening of soft tissues (glycosylation) occurs, especially in ligaments around jointslimited joint mobility syndrome. Intubation may be difficult if the neck is affected or there is insufficient mouth opening. Gastrointestinal: 50% have delayed gastric emptying and are prone to reflux. Diabetics are prone to infections

Preoperative Management

Place the patient early on operating schedule if possible. Stop long-acting oral hypoglycemics, e.g., metformin and glyburide, 24 hr before surgery. Chlorpropramide should ideally be stopped 3 d before surgery because of its long action and substituted with a shorter-acting drug such as glyburide or glipizide.

Barrash

Preoperative Glucose Management Anesthesia and surgery interrupt the regular meal schedule and insulin administration of diabetics. Perioperative stress may increase serum glucose concentrations secondary to the release of cortisol and catecholamines. The majority of available literature suggests that better glycemic control may limit morbidity (length of hospital/intensive care unit stay, infection rate, wound healing, outcomes after strokes/MIs) and mortality particularly in cardiac surgery patients, carotid endarterectomy patients, and the critically ill,56,58,59,60 although a recent randomized trial found an increase in the incidence of death and perioperative stroke in cardiac surgery patients where an attempt was made to maintain the glucose between 80 and 100 mg/dL.61 More studies are needed to determine whether strict glycemic control will improve outcome in all diabetics undergoing surgery. Because good evidence is lacking to be able to set standards for the perioperative glucose management of diabetic patients, at a minimum, an attempt should be made to control the glucose within a range of 100 to 200 mg/dL, although some will argue that tighter control with a top limit of 150 mg/dL is warranted. The following recommendations can serve as a general guide:

Plan with the surgeon to schedule the surgery as the first case of the day to prevent prolonged fasting. As a general rule, oral hypoglycemic agents are held on the day of surgery to avoid reactive hypoglycemia. The exception is metformin, which should be held for at least 24 hours preoperatively to avoid the risk drug-induced lactic acidosis. Insulin should be continued through the evening before surgery, including the usual dose of insulin glargine (Lantus). Patients should be counseled to take a glucose tablet or clear juice if hypoglycemia occurs prior to arrival at the hospital, in order to prevent delay of the surgery.

Schedule the patient to arrive without having ingested anything by mouth in early morning and check blood glucose, electrolytes, and ketones. Type 1 diabetics should be continued on basal insulin replacement even while nothing by mouth status to prevent ketoacidosis. Administer half the usual morning dose of intermediate- or long-acting insulin after arrival to the surgery center, but hold the usual dose of rapid- or short-acting insulin. Patients on insulin pumps may be managed by continuing the pump for short surgeries, or changing over to an intravenous insulin infusion for moderate or major surgeries. Use the patient's own sliding scale to administer a short-acting insulin subcutaneously to maintain the glucose between 100 and 200 mg/dL prior to the scheduled surgery.

This strategy, along with blood glucose determinations every 1 to 2 hours, may be all that is necessary for well-controlled diabetics undergoing short, noninvasive outpatient surgeries. Additionally, it is important to prevent postoperative nausea and vomiting and to encourage the early resumption of diet, allowing return to their previous insulin regimen. For type 1 or 2 diabetics undergoing moderate or major surgery, insulin is generally administered in the form of an infusion of regular insulin. Discontinuing the patient's own insulin pump to avoid problems with insulin preparations and pump technology is often advised. There are several methods of administering an insulin infusion, none of which has proved superior to the others. Some recommend a combined infusion of glucose, insulin, and potassium because of the inherent safety of avoiding the possibility of having a glucose infusion inadvertently stopped while an insulin infusion continues. However, concurrent separate infusions of insulin and glucose are more easily adjusted and may provide better glycemic control. To increase the safety, the insulin infusion (which is on a separate pump) is added via a side port to the same line delivering the glucose infusion. A separate nonglucose isotonic solution should be used to replace deficits and intraoperative fluid losses. All protocols rely on the frequent determination of a plasma glucose level at least every 1 to 2 hours to allow titration of insulin.62,63,64