Uncontrolled Diabetic coming for Emergency Laprotomy

Introduction
Diabetes refers to excessive production and excretion of urine. Mellitus literally means honey and refers to abnormally elevated concentrations of glucose in blood and urine

Table 344-2 Criteria for the Diagnosis of Diabetes Mellitus

Symptoms of diabetes plus random blood glucose concentration mg/dL)aor

11.1 mmol/L (200

Fasting plasma glucose

7.0 mmol/L (126 mg/dL)bor

A1C > 6.5%cor

Two-hour plasma glucose testd

11.1 mmol/L (200 mg/dL) during an oral glucose tolerance

Uncontrolled / poorly controlled diabetic may usually present with complications Asian Indians are more prone to diabetes as well as its complications Certain complications like coronary artery disease and Nepropathy are more common in Indians Diabetics can present in any scenario The Annual rate of Diabetic Acidosis was 46 per 10000 individuals with Diabetes. Of these 87% were on insulin prior to admission and 81% were not Obese. The youngest children were at greatest risk. The prevalence of diabetic complications are given below

PREVALENCE OF DIABETIC COMPLICATIONS IN INDIA

SNO 1 Diabetic nephropathy YEAR AUTHOR 2010 PLACE SETTING Clinic based SAMPLE SIZE PREVALENCE MAU 25.5 % Macroproteinuri a 16.2% Kanakman New i et al13 Delhi 640 T 2DM Median duration of diabetes 5 years Ahmada Population 40919 people bad based screened for diabetes Chandig Clinical 1044 T 2DM arh based Chennai Clinical based 1377 Urban 1265 Rural

Diabetic retinopathy Diabetic peripheral neuropathy Diabetic peripheral vascular disease Diabetic foot

2009

Vyas et al20 Jayapraka sh et al30 Viswantha n et al43

2009

10.8 % both 14.6 % (neuly diabetes ) 34.9 %

2006

15 % Urban 13 % Rural

2010

Viswantha n et al51

India

Clinical based

Coronary artery disease Tuberculosis

2009

Bharadwaj et al53 Shety et al73

2006

Himach al Pradesh Bangalo Case re control study

526 T 2DM subjects (India 194, Bangladesh 177, Tanzania 155) who had undergone major amputation Population 33patients with based CAD 189 patients with newly diagnosed pulmonary Tuberculosis and matched controls

Re amputation rate 3% at each site recurrence of ulcer 9 % mortality 16 % in India

2 of 33 patients had diabetes Odds ratio for developing Tuberculosis for diabetes 1.8

it as been clearly shown that better glycemic control in diabetics undergoing surgery improves out come uncontrolled diabetic should not be taken up for elective surgery before correction of complications

CASE STUDY
A male patient aged 17 years came with Fever with chills & rigors since 3days SOB since 2days, Vomitings since morning,3times, Severe Thirst Diabetic diagnosed 2 years back & on irregular Insulin treatment.

This case is also presented with severe abdominal pain in the epigastric area .and posted for emergency laprotomy O/E : Dehydrated PR : 152 / mt BP : 120 / 80 mm of Hg RR : 38 / min , Tachypnoeic SpO2 : 91% on Room air CVS : S1 S2 + RS : BAE+

Investigations
Hb : 17.4 gm% TLC : 24.9 cells/ c.mm Platelets : 4.05 lacs/c.mm BUN : 29.4 mg/dl S.creatinine : 0.7 mg/dl

 ABG PaO2 PaCO2 pH Hco3 (actual) Hco3 (std.) BE BE ecf AG S.electrolytes : Na : 139 meq/l Cl : 114 meq/l , BGL : high, urine ketone bodies : + ve K : 2.6meq/l, Ca : 8.3 meq/l, Mg 1.9 meq/l 104.5 mm Hg 25.4 mm Hg 7.418 16.0 mmol/L 19.1 -13.8 mmol/L -15.9 mmol/L 28.1 mmol/l

Management
Correction of Complications Correction of Dehydration Correction of Acidosis & electrolytes Correction of Hyperglycemia Control of INFECTION

DKA
Common In type 1 DM Symptoms : 1. 2. 3. 4. 5. Dyspnoea, Abdominal pain, Nausea and vomiting, Dehydration, Coma

 Anion-gap metabolic acidosis, elevated plasma and urine ketones (acetoacetate, beta-hyroxybutyrate), hyperglycemia DKA Treatment 1. Fluid resuscitation-NS@ 1L/hr for two hrs. Then 500ml/hr for 4hrs, then 250ml/hr for 4hrs .Add D5W when plasma glucose 250 mg% 2. Insulin (regular)- 10u IV bolus is optional . 0.1 U/kg/hour infusion and increase or decrease based on Bl.Sugar level

3. Potassium -when urine output is there <3 meq 3-4 meq 4-5 meq 40meq/hr, 30meq/hr, 20meq/hr

Insulin Infusion Rate (U / DL)

Patient Blood Glucose Level (MG/DL)
Algorithm - 1 Algorithm 2 Algorithm 3 Algorithm - 4

< 60 = Hypoglycemia (see below for treatment) < 70 0 0 0 70 109 0.2 0.5 1 110 119 0.5 1 2 120 149 1 1.5 3 150 179 1.5 2 4 180 209 2 3 5 210 239 2 4 6 240 269 3 5 8 270 299 3 6 10 300 329 4 7 12 330 359 4 8 14 > 360 6 12 16

0 1.5 3 5 7 9 12 16 20 24 28 28

Hyperosmolar nonketotic coma

Hyperglycemic diuresis -> severe dehydration Renal failure Lactic acidosis Risk of intravascular thromboses Hyperosmolality with coma seizures

Treatment
Fluid resuscitation Insulin (relatively small doses) Potassium when urine output.

Hypoglycemia
Diaphoresis, tachycardia, nervousness Plasma glucose < 50 mg% Treatment: 50ml of 50% dextrose

If surgery is urgent GIK (glucose- insulin potassium ) drip is useful to achieve rapid controlled Anaesthesiologist encounter diabetics for Incidental surgery Surgery related to the disease. Pregnancy I.C.U

Anaesthetic Implications Coronary artery disease Peripheral vascular disease Cerebrovascular disease Renal disease Respiratory and air way changes Autonomic neuropathy

Cardiovascular system Increased risk of CAD and MI Silent myocardial ischemia and infarction cardiomyopathy in the face of angiographically normal coronary arteries,.

Respiratory and air way changes Significant decrease in lung volumes and diffusing capacity Decrease in vital capacity. Stiff joint syndrome. Acute unexplained hypoxia in post op period. Post op respiratory arrest. Stiff Joint Syndrome One of four adolescent diabetics Stiff joints due to nonenzymatic glycosylation of the Decreased mobility of the atlanto-occipital joint. Prayer sign Palm print sign collagen tissues.

Renal System Diabetic nephropathy -up to 4050% of IDDM Albuminuria usually precedes a steady decline in renal function Fluid and electrolyte imbalance Delayed metabolism and altered excretion of anesthetic drugs Autonomic Neuropathy Up to 40% in type I & 17% in type II Postural hypotension Profound Intraoperative hypotension with SA requiring vasopressor support Perioperative cardiorespiratory arrest Exaggerated pressor response to tracheal intubation Delayed gastric emptying with increased risk of aspiration Signs of Autonomic Neuropathy Lack of sweating Early satiety Orthostatic hypotension Gastric reflux Lack of heart rate variability with deep inspiration. Impotence and urinary symptoms of Dysautonomic bladder may be evident. Dependent oedema Gustatory sweating

TESTS FOR ANS Measuring the beat-to-beat variation in heart rate during breathing, Heart rate response to a Valsalva maneuver, Orthostatic changes in blood pressure and heart rate. B.P response to sustained hand grip Changes in the heart rate Parasympathetic system Changes in the blood pressure - Sympathetic system

Preanaesthetic Evaluation A thorough search for end-organ complications of Diabetes A thorough history and physical Examination Severity and type of diabetic state Medication for diabetes and control of blood sugar. Associated co morbidities Air way assessment

Investigations Blood Glucose, Blood urea , Serum creatinine, serum electrolytes (esp-Potassium), Recent ECG and CXR Urine analysis for sugar and ketones Glycosylated Hb (HbA1C) to assess glycemic control

Type of Anaesthesia (Regional Vs General) Regional anesthesia Advantages 1. Alleviates stress response to surgery. 2. Decrease in incidence of thrombo embolism 3. Avoidance of aspiration and difficult air way problems. 4. Avoidance of poly pharmacy and their effects on diabetic status Disadvantages 1. Cardiovascular instability 2. Exacerbation of peripheral neuropathy 3. Increased risk of infection GA Drugs Halothane, Methoxyflurane, and Thiopental- Nitrous oxide anesthesia, increase blood glucose level. Enflurane and spinal anesthesia.- no increase in bl.glucose level. .Muscle relaxants and premedicant drugs in common use today are of little concern to diabetics Overall, the metabolic effects of modern anesthetics are minor compared with the stress of surgery itself

Perioperative management The important points to consider when preparing a diabetic patient for surgery include the - Nature and urgency of surgery, - Treatment regimen used, and diet. The aim of perioperative glycaemia control is to avoid Hypoglycaemia, excessive Hyperglycaemia, Ketoacidosis, and Electrolyte disturbances. A blood glucose range between 6.7 10 mmol /L (120-180 mg %), is widely accepted - Adequacy of blood glucose control, - Anticipated time of return to normal

Monitoring Blood pressure, Temperature, Pulse oximetry, Continuous monitoring of E.C.G Capnogram, Frequent determinations of both blood and urine glucose should be made. Urine out put

I.V.FLUIDS On the basis of a preoperative osmotic diuresis, the diabetic patient may reach the operating room with clinically significant dehydration. In addition to the usual principles of perioperative fluid management, it is important to note the amount of glucose administered iv to avoid a massive overdose of glucose. Patients with diabetes should receive approximately 5 g of glucose per hour (i.e., 5 percent dextrose solution in water infused at 100 mL per hour) during surgery to prevent the development of hypoglycemia, ketosis, or protein breakdown

I.V.FLUIDS(cont) It would be wrong to give large amounts of dextrose (contained in the iv solutions) just because that patient needed vigorous fluid replacement. N.S (0.9%NaCl) is the ideal crystalloid , R.L increases the blood sugar level after conversion .(k+ is given in the form of KCl) Basing on the blood loss and Hct value fresh blood should be given Perioperative fluid management depends up on cardiac and renal status of the patient . Targets of Glycemic control Ideal to keep blood sugar between 120 180 mg / dL

In tight control , for selected cases between 80 120 mg / dL To prevent hypoglycemia Monitoring electrolytes especially potassium Hemodynamic stability

Insulin therapy Soluble insulin by I.V route is preferable Insulin can be given either by 1. fixed rate with glucose infusion 2. separate and adjustable infusion In well controlled diabetics, Isophane insulin can also be continued.

Diabetic Pts who are not treated with insulin Minor Surgery + Good Glycemic Control Replace any long acting sulfonyl ureas Admit on the day before surgery On the day of surgery Operate in the morning if possible Omit breakfast and oral agents Avoid glucose containing infusions Monitor blood glucose 2 nd hrly Post Operatively Monitor blood glucose frequently Restart oral agents with first post op meal

Diabetic Pts who are not treated with insulin Major Surgery + Poor Glycemic Control Admit 2-3days before surgery Stabilize with short acting insulin On the day of surgery Operate in morning if possible Omit break fast and insulin inj Start iv insulin &glucose( or separate line) Monitor blood glucose 2ndhrly Post Operatively Monitor blood glucose frequently

Transfer to sc insulin if unstable control Restart oral agents when stabilized Diabetic patients who are treated with Insulin Admit 2-3days before surgery Stabilize control if necessary On the day of surgery Operate in morning if possible Omit break fast and insulin inj Start iv Insulin & Glucose (GKI or separate lines) Monitor blood glucose hrly Post Operatively Monitor blood glucose frequently Restart sc insulin with 1st post op meal Discontinue iv insulin 2-3 hrs later GIK 500ML 10%GLUCOSE 10U SOL INSULIN 10MEQ OF POTASSIUM NON TIGHT CONTROL OF BL.SUGAR No insulin ,No glucose Simple & still being followed by many FBS on the morning of surgery.

Disadv- pre op glucose may be normal but intra oplevel may be high Suitable only for brief procedure eg-dilatation, curettage & cystoscopy. Food intake is delayed only by an hour or two

 Routine management is restarted at the earliest

NON TIGHT CONTROL OF BL.SUGAR Partial morning dose of insulin FBS on the morning of surgery. Partial morning dose of insulin SC and Dextrose infusion Dis adv- SC route is not predictable : does not provide good glycemic control. Not a very popular regimen TIGHT CONTROL OF BL.SUGAR To keep glucose between 80-120mg/dl REGIMEN-1 Preprandial sugar levels on the evening before surgery.

Start infusion , piggyback regular insulin 50u in 250ml 0.9nacl Flush this line at least 60ml of this sol to prevent adsorption of insulin. Infusion rate = plasma glucose/150 (100-pt on steroids). Repeat measurements of glucose 4th hrly and adjust insulin to achieve plasma glucose of 100200 mg/dl

TIGHT CONTROL OF BL.SUGAR On the day of surgery-use non dextrose containing fluids for intra operative use Determine plasma glucose 2nd hrly and infuse insulin accordingly Frequent change of sol pose an attendant risk of hyponatremia. If the glucose level are < 90 mg/dl discontinue insulin and estimate the blood glucose level every 30 min till glucose is >110mg/dl. Serum k+ should be checked and adjusted accordingly with particular care for poor renal function.

TIGHT CONTROL OF BL.SUGAR TO KEEP GLUCOSE BETWEEN 80-120mg/dl REGIMEN-2 Fixed rate glucose infusion Separate and adjustable infusion of insulin to maintain normoglycemia Insulin requirements vary between 0.5 to 5u/hrly in post op period Advantages :it is easy to follow ,but requires good communication skills between nurse and doctor Sliding scale insulin infusion

GLUCOSE CONC

Insulin u/hr infusion rate 1 1 .5 2 3 4 6

<70 71-125 126-160 161-200 201-300 301-500 >500

GHT CONTROL OF BL.SUGAR The Artificial Pancreas Close loop controlled: The glucose and insulin are infusion is determined by an online plasma analyser Plasma glucose level maintained between 70 -120mg/dl Very expensive ,require complex supervision and used at present in reseach environment. Alberti-Thomas regimen Before operation stabilize 2-3 days prior to surgery with short-acting insulin (Actrapid). During operation - Give NO subcutaneous insulin on day of surgery. Set up an infusion of 10% glucose (500ml) containing Actrapid 10 units plus KCl 1g. Give it at the rate of 100-125ml/hr. Check blood glucose and plasma potassium before infusion and after 2-3 hours. Adjust the amount of insulin as follows: <5 5 10 > 10 > 20 Blood glucose (mmol L-1) < 90 mg 90-180 mg >180 mg >360 mg Infusion

10% glucose 500ml + insulin 5 units + KCl 1g 10% glucose 500ml + insulin 10 units + KCl 1g 10% glucose 500ml + insulin 15 units + KCl 1g 10% glucose 500ml + insulin 20 units + KCl 1g

Adjust potassium doses according to plasma potassium level. Disadvantage: Cumbersome and requiring periodacal alternationa Christian Medical College & Hospital regimen A burette set is connected to a 5% glucose (500ml) bag, and 100 ml of glucose is filled into the burette at a time. Short-acting insulin (Actrapid) is added to the 100 ml of fluid in the burette according to the scale given below and this is infused over 1 h.

Blood glucose is measured at the end of the hour which determines the amount of insulin to be added to the next 100ml of 5% glucose.

Blood glucose mg/dl (mmol L-1) <75 (4.1)

Infusion No insulin; 100ml 5% glucose over 15 min No insulin; 100ml 5% glucose over 1h 1U Actrapid in 100ml 5% glucose over 1h 2U Actrapid in 100ml 5% glucose over 1h 3U Actrapid in 100ml 5% glucose over 1h 4U Actrapid in 100ml 5% glucose over 1h 4U Actrapid in 100ml normal saline over 1h

75-100 (4.1-5.5) 100-150 (5.5-8.3) 150-200 (8.3-11.1) 200-250 (11.1-13.8) 250-300 (13.8-16.6) >300 POSITIONING (16.6)

Positioning of the pt is very important. Injuries to the limbs or nerves are more likely as they are already compromised by diabetic peripheral vascular disease or neuropathy. The peripheral nerves may already be partly ischemic and therefore particularly vulnerable to pressure or stretch injuries. INTRAOPERATIVE HYPOGLYCEMIC SHOCK It is virtually impossible to differentiate hypoglycemic shock from other forms of shock intraoperatively unless supported by low blood glucose concentrations measured concomitantly. Treatment lies in administration of glucose, which can be given as a bolus of 50% glucose followed by a 10% glucose-insulin infusion.

 Blood sugar increases approximately 30 mg/dl for each 7.5-g bolus of dextrose in a 70-kg adult.

POSTOPERATIVE COMPLICATIONS In addition to the usual complications, the common problems in a diabetic include poor diabetes control and infection. A higher incidence of cardiovascular and renal problems and autonomic neuropathy, resulting in postural hypotension and urinary retention, may be encountered. Overall morbidity and mortality are increased